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Presented  by 
Edythe  F.  Ashmore,   D.o. 


COLLEGE    OF    OSTEOPATHIC     PHYSICIANS 
AND  SURGEONS  •    LOS  ANGELES,  CALIFORNIA 


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INFECTIONS  OF  THE  HAND 


A  GUIDE  TO  THE  SURGICAL  TREATMENT  OF 

ACUTE  AND  CHRONIC  SUPPURATIVE 

PROCESSES  IN  THE  FINGERS, 

HAND,  AND  FOREARM 


BY 


ALLEN   B.  KANAVEL,  M.D. 

ASSISTANT   PROFESSOR   OF    SURGERY,    NORTHWESTERN    UNIVERSITY  MEDICAL   SCHOOL 
ATTENDING   SURGEON,    WESLEY  AND   COOK  COUNTY   HOSPITALS,   CHICAGO 


SECOND  EDITION,  THOROUGHLY  REVISED 


Illustrates  witb  147 


LEA    &  FEBIGER 

PHILADELPHIA    AND    NEW    YORK 


2 


Entered  according  to  the  Act  of  Congress,  in  the  year  1914,  by 

LEA    &    FEBIGER, 
in  the  Office  of  the  Librarian  of  Congress.     All  rights  reserved. 


PREFACE  TO  SECOND  EDITION 


IN  the  presentation  of  a  contribution  such  as  this, 
an  author  is  at  a  loss  to  know  just  how  much  of  the 
experimental  and  anatomical  investigations  upon  which 
his  surgical  deductions  are  based  should  be  included. 
Upon  one  hand  is  the  fear  that,  if  too  much  is  intro- 
duced, the  practical  surgical  deductions  will  be  lost  to 
the  busy  and  hurried  practitioner  who  first  sees  these 
cases;  upon  the  other,  if  dogmatic  statements  are  made 
as  to  diagnosis  and  therapy,  although  based  on  sound 

^  reasoning  and  true  for  the  great  majority  of  cases,  the 
-  careful  surgeon  will  lack  the  basal  facts  upon  which  he 
can  diagnosticate  and  treat  the  atypical  and  hence 
more  dreaded  cases.  The  author  has,  therefore, 
attempted  so  to  arrange  the  results  of  his  experimental 
work  that,  although  all  of  the  facts  are  given  upon 
which  deductions  can  be  made  in  the  latter  cases,  the 
chapters  are  so  grouped  that  the  busy  practitioner 

-   can    find    the   part    dealing  with    his    particular   case 
quickly. 

Given  a  case  in  which  the  practitioner  is  in  doubt, 
he  should  read  the  chapter  upon  "Diagnosis  and 
Treatment  in  General."  This  will  indicate  the  group 
into  which  his  case  falls,  and  will  also  direct  him  to  the 
proper  sections  of  the  book  where  cases  of  that  nature 
are  treated  more  in  detail. 

The  present  revision  has  given  the  author  an  oppor- 
tunity to  make  certain  additions  in  regard  to  the 
chronic  processes,  which  his  experience  in  the  last 
two  years  has  suggested.  It  has  also  made  it  possible 


4294 


iv  PREFACE  TO  SECOND  EDITION 

for  him  to  act  upon  the  suggestions  made  by  various 
reviewers  particularly  in  relation  to  more  complete 
descriptions  under  illustrations  of  cross-sections,  and 
a  clearer  system  of  cross-references.  It  is  a  pleasure 
to  say  that  further  experience  has  justified  the  state- 
ments made  in  the  first  edition  as  to  the  value  of  the 
various  incisions  in  the  treatment  of  the  individual 
types  of  infection. 

Following  several  of  the  chapters,  resumes  have 
been  inserted  which  it  is  believed  will  aid  the  surgeon 
who  is  in  haste  for  concrete  knowledge  concerning 
the  contents  of  the  chapters,  but  the  author  wishes 
emphatically  to  warn  the  student  and  surgeon  that  a 
comprehensive  reading  of  the  preliminary  anatomical 
and  experimental  work  will  be  necessary  for  an  accurate 
knowledge  of  the  diagnosis  of  the  various  types  of 
infection  and  the  position  of  the  pus  in  each  type. 

In  conclusion  it  may  not  be  out  of  place  to  emphasize 
again  the  necessity  for  careful  study  of  the  diagnosis 
of  tendon-sheath  infection,  which,  in  the  majority 
of  cases,  is  overlooked  until  it  is  too  late  for  satis- 
factory treatment.  If  each  surgeon  wrould  have  in 
mind  this  possibility  and  be  constantly  on  his  guard, 
so  that  the  proper  operation  might  be  performed 
promptly,  the  usefulness  of  many  a  hand  that  is  now 
lost  would  be  preserved. 

The  author  takes  this  opportunity  to  make  acknowl- 
edgment of  the  many  courtesies,  in  the  way  of  per- 
mission to  study  cases,  which  have  been  received  from 
members  of  the  profession  at  large,  including  Dr.  Van 
Hook,  Dr.  Martin,  and  his  co-workers  in  the  Surgical 
Department  of  the  Northwestern  University  Medical 
School,  Drs.  Besley  and  Richter.  He  feels  a  particular 
obligation  to  the  anatomical  department,  its  various 
instructors  and  students,  who  have  been  of  great 
assistance  on  many  occasions. 


PREFACE  TO  SECOND  EDITION  v 

To  his  surgical  assistants,  Dr.  Cushway,  Dr.  Eustace, 
and  Dr.  Wolfer,  and  to  many  others  not  so  intimately 
associated  with  his  work,  he  wishes  to  express  his 
appreciation  of  their  help  in  the  care  and  study  of 
the  individual  cases. 

He  also  wishes  to  express  his  appreciation  of  Miss 
Spencer's  careful  work  in  assisting  in  the  preparation 
of  the  text,  and  to  make  acknowledgment  to  Miss 
Hamlin  for  her  care  and  attention  in  the  revision. 

Surgery,  Gynecology,  and  Obstetrics  has  kindly  given 
permission  to  use  certain  plates  from  the  author's 
articles  published  in  that  journal. 

A.  B.  K. 

CHICAGO,  1914. 


CONTENTS 


CHAPTER  I 

INTRODUCTION:   SCOPE  AND  CLASSIFICATION  OF 
TYPES  OF  INFECTIONS 

History 17 

Scope  and  Classification  of  Types 20 


PART   I 

SIMPLE  LOCALIZED  INFECTIONS  AND  ALLIED  MINOR 
CLINICAL  ENTITIES 

CHAPTER  II 

INFECTIONS  OF  THE  DISTAL  PHALANGES 

Felons 25 

Treatment 29 

Paronychia 31 

Treatment 33 

Subepithelial  Abscesses 37 


Anatomical  Considerations  and  Pathogenesis 38 

Treatment 42 

Differential  Diagnosis ,  47 

Oidiomycosis 47 

Chronic  Staphylococcus  Processes 49 

CHAPTER  IV 

MISCELLANEOUS  ABSCESSES 

Collar-button  Abscess  (Shirt-stud  Abscess)  (Frog-Felon)        ....  52 

Treatment 54 

Localized  Abscesses  in  the  Thenar  and  Hypothenar  Spaces    ....  55 


viii  CONTENTS 


PART   II 

GRAVE  INFECTIONS:   TENOSYNOVITIS,  FASCIAL-SPACE 
ABSCESSES,  LYMPHANGITIS,  AND  ALLIED 
CONDITIONS 

CHAPTER  V 
DIAGNOSIS  IN  GENERAL 

Lymphangitis 58 

Tenosynovitis 59 

Fascial-space  Infection 63 

Diagnosis  of  Extensions  from  Various  Sites 68 

CHAPTER  VI 

GENERAL  PRINCIPLES  OF  TREATMENT 

Prophylaxis 70 

Rest 70 

Drugs 71 

Passive  Hyperemia 71 

Hot,  Moist  Dressings 72 

Prophylactic  Incision 74 

Drainage 76 

Stimulation  of  Excretion 77 

Massage 78 

Baking  in  Dry,  Hot  Air 78 


SECTION  I 

THE  ANATOMY  OF  THE  HAND  AND  FOREARM,  WITH  ESPECIAL 
CONSIDERATION  OF  ITS  RELATION  TO  INFECTIONS  OF 
THE  SYNOVIAL  SHEATHS  AND  FASCIAL  SPACES 

CHAPTER  VII 

METHODS  OF  STUDY   IN  GENERAL:  A  STUDY  OF  SERIAL 
CROSS-SECTIONS   OF   THE    HAND,   WITH    PARTICULAR 
RELATION     TO     THE     FASCIAL     SPACES 

Methods  of  Study 80 

A  study  of  Serial  Cross-sections,  with  Particular  Relation  to  the  Fascial 

Spaces 83 

Middle  Palmar  Space 90 

Thenar  Space  .    • 91 

Hypothenar  Space 95 

Discussion  of  the  Relation  of  the  Middle  Palmar  and  Thenar 

Spaces 97 

R<§sum6  100 


CONTENTS  ix 

CHAPTER  VIII 

THE  TENDON  SHEATHS:    A  DISCUSSION  OF  THEIR 

ANATOMICAL  DISTRIBUTION  AND  RELATIONS, 

WITH  SURGICAL  DEDUCTIONS 

Sheaths  upon  the  Flexor  Surface 102 

The  Sheaths  of  the  Index,  Middle,  and  Ring  Fingers  .  .  .  103 
The  Radial  Bursa  and  the  Tendon  Sheath  of  the  Flexor  Longus 

Pollicis 105 

The  Ulnar  Bursa  and  the  Sheath  of  the  Tendon  of  the  Little 

Finger 106 

The  Intercommunication  of  the  Sheaths no 

Sheaths  upon  the  Dorsum .114 

CHAPTER  IX 

THE  RELATION  BETWEEN  THE  SYNOVIAL  SHEATHS  AND 

THE  FASCIAL  SPACES— A  STUDY  BY  EXPERIMENTAL 

INJECTION  OF  THE  OUTLINES,  BOUNDARIES,  AND 

DIVERTICULA  OF  THE  FASCIAL  SPACES  AND 

THE  RELATION   OF  THESE  TO   THE 

SYNOVIAL  SHEATHS 

The  Relation  of  the  Tendon-sheath  Rupture  to  the  Fascial  Spaces        .  1 1 8 

Injection  via  the  Tendon  Sheath  of  the  Middle  Finger  .  .  .  118 
Injection  via  the  Tendon  Sheath  of  the  Ring  Finger  ...  .119 
Injection  via  the  Tendon  Sheath  of  the  Little  Finger  ...  .120 

Injection  via  the  Tendon  Sheath  of  the  Index  Finger      ....  125 

Injection  via  the  Tendon  Sheath  of  the  Flexor  Longus  Pollicis  .  126 
General  Deductions  as  to  Relation  of  Tendon  Sheaths  to  Facial 

Spaces 127 

The  Normal  Boundaries  of    the  Fascial  Spaces  and  the  Position  of 

Secondary  Abscesses  in  Case  of  Extension  from  the  Spaces    .      .  128 

The  Middle  Palmar  Space 128 

Injection  via  the  Tendon  Sheath  of  the  Ring  Finger      .      .      .  128 

Injection  through  Palmar  Fascia  into  Middle  Palmar  Space    .  133 

Injection  along  Lumbrical  Muscle  of  the  Ring  Finger   .      .      .  134 

Thenar  Space 134 

Injection  via  the  Tendon  Sheath  of  the  Index  Finger    .      .      .  135 

Injection  of  the  Thenar  Space  under  Forcible  Presure  .      .      .  136 
Injection  Through  Palmar  Fascia  in  Attempt  to  Reach  the 

Thenar  Space 140 

Dorsal  Subcutaneous  Space 141 

Injection  between  the  First  and  Second  Metacarpals     .      .     ".  141 

Injection  between  the  Second  and  Third  Metacarpals  .      .      .  142 

Dorsal  Subaponeurotic  Space 142 

Injection  under  Tendons  of  Dorsum 142 

Hypothenar  Space 144 

Re'sume'  of  Preceding  Experiments  as  to  Boundaries,  Diverticula, 

and  Extensions  from  the  Fascial  Spaces 144 


CONTENTS 


Anatomy  in  General 149 

Serial  Cross-sections  of  the  Forearm 150 

Experimental  Injections  of  the  Fascial  Spaces  of  the  Forearm     .      .      .  154 

Injection  of  the  Radial  Bursa 155 

Injection  of  the  Ulnar  Bursa 156 

Injection  from  the  Mid-palmar  Space 157 

Resume  of  Findings  by  Dissection  and  Experimental  Injection  .      .      .  159 


SECTION  II 

THE  SURGICAL  CONSIDERATIONS  OF  TENDON-SHEATH 

INFECTIONS  AND  FASCIAL-SPACE  ABSCESSES  OF 

THE  HAND  AND  FOREARM 


CHAPTER  XI 

PATHOGENESIS— SOURCE  OF  INVOLVEMENT  OF  THE 
TENDON  SHEATHS  AND  FASCIAL  SPACES 

Etiology  in  General 163 

Source  of  Involvement  of  the  Various  Sheaths 164 

Extension  from  One  Sheath  to  Another 166 

Source  of  Involvement  of  the  Important  Fascial  Spaces  in  the  Hand     .  168 

Involvement  from  the  Tendon  Sheaths .  *  .  168 

Direct  Implantation  of  the  Infection  in  the*  Spaces 169 

Involvement  by  Lymphatic.  Ex  tension 173 

Extension  from  One  Fascial  Space  to  Another 175 

Recapitulation  as  to  Source  of  Involvement  of  the  Fascial  Spaces  183 


CHAPTER  XII 

THE  SPREAD  OF  INFECTION  FROM  ANY  GIVEN  PRIMARY 

FOCUS 

The  Probable  Extensions  from  Primary  Foci  on  the  Fingers        .      .      .  185 

The  Spread  of  Infection  Involving  the  Index  Finger        ....  185 

The  Spread  of  Infection  Involving  the  Thumb 195 

The  Spread  of  Infection  Involving  the  Middle  Finger     ....  196 

The  Spread  of  Infection  Involving  the  Ring  Finger 197 

Infection  Spreading  from  the  Little  Finger 199 

Infections  Beginning  in  the  Palm  and  Dorsum 200 

Re'sume'  201 


CONTENTS  xi 


CHAPTER  XIII 

THE  PATHOLOGY  OF  TENDON  SHEATH  AND   FASCIAL-SPACE 

ABSCESSES 

The  Tendon  Sheath  Proper 204 

The  Fascial-space  Abscesses    .........            .-  206 

CHAPTER  XIV 

THE  SYMPTOMS,  SIGNS,  AND  DIAGNOSIS  OF  TENOSYNOVITIS 
AND  FASCIAL-SPACE  ABSCESSES 

The  Symptoms,  Signs,  and  Diagnosis  of  Acute  Tenosynovitis       .      .      .  209 
Symptoms,  Signs,  and  Diagnosis  of  Extensions  from  Infections 

Beginning  in  the  Little  Finger 212 

Extension  to  Ulner  Bursa 212 

Extension  to  Radial  Bursa        .      .     ^ 215 

Extension  to  Forearm 215 

Extension  to  Lumbrical  and  Palmar  Spaces 216 

Symptoms,  Signs,  and  Diagnosis  of  Extensions  from  Infections 

beginning  in  the  Index,  Middle,  and  Ring  Fingers       .      .      .      .  218 
Symptoms,  Signs,  and  Diagnosis  of  Extensions  from  Infections 

Beginning  in  the  Radial  Bursa 221 

The  Symptoms,  Signs,  and  Diagnosis  of  Fascial-space  Abscesses       .      .  223 

The  Middle  Palmar  and  Thenar  Spaces 224 

The  Hypothenar  Space 231 

The  Dorsal  Abscesses 231 

Forearm  Abscesses 232 

Differential  Diagnosis • 233 

CHAPTER  XV 

THE  TREATMENT  OF  ACUTE   SUPPURATIVE   TENOSYNOVITIS 

—GENERAL  CONSIDERATIONS— A  REVIEW  OF  THE 

LITERATURE 

Excerpts  from  the  Literature 236 

CHAPTER  XVI 

THE  TREATMENT  OF  ACUTE   SUPPURATIVE  TENOSYNOVITIS 
—DISCUSSION  OF  TECHNIQUE 

Treatment  While  the  Diagnosis  May  Be  in  Doubt 256 

Technique  of  Treatment  after  Diagnosis  is  Made 257 

Treatment    of    Tenosynovitis    of    the    Index,    Middle,  and    Ring 

Fingers 259 

When  the  Involvement  of  Adjacent  Areas  has  Begun        .      .      .  261 

The  Index  Finger 261 

The  Middle  Finger 263 

The  Ring  Finger 263 


xii  CONTENTS 

Technique  of  Treatment  after  Diagnosis  is  Made — 

Treatment    of    Tenosynovitis    of    the    Little    Finger    and   Ulnar 

Bursa 263 

Treatment  of  Extensions  from  the  Little  Finger  and  the  Ulner 

Bursa 270 

Treatment  of  Inflammation  of  the  Tendon  Sheath  of  the  Long 

Flexor  of  the  Thumb 273 

Treatment  of  Inflammation  of  the  Synovial   Sheaths  upon  the 

Dorsum 283 

After-treatment 284 


CHAPTER  XVII 

THE  TREATMENT  OF  FASCIAL-SPACE  ABSCESSES 

Technique  of  Treatment  of  Abscesses  in  the  Middle  Palmar  Space  .      .  290 
The  Treatment  of  Combined  Involvement  of  the  Middle  Palmar 

and  Thenar  Spaces 293 

The  Treatment  of  Combined  Involvement  of  the  Middle  Palmar 

and  Subaponeurotic  Spaces 297 

Technique  of  Treatment  of  Abscesses  in  the  Thenar  Space    .      .      .      .301 

Technique  of  Treatment  of  Abscesses  of  the  Subaponeurotic  Space        .  303 

After-treatment  in  Fascial-space  Abscesses 304 


CHAPTER  XVIII 

RESUME  OF  ACUTE  SUPPURATIVE  TENOSYNOVITIS  AND 
FASCIAL-SPACE   ABSCESSES— PROGNOSIS 

Resume 305 

Prognosis 307 


SECTION  III 

LYMPHATIC    INFECTIONS 
CHAPTER  XIX 

THE  RELATION  OF  LYMPHANGITIS  TO  OTHER  TYPES  OF 
INFECTION— DISCUSSION  OF  THE  ANATOMY 

The  Relation  of  Lymphangitis  to  Other  Types  of  Infection         .      .      .  309 

Anatomy 310 

The  Lymphatic  Vessels  of  the  Hand  and  Forearm 312 

Superficial  Lymphatics 312 

Deep  Lymphatics 320 


CONTENTS  xiii 


CHAPTER  XX 

LYMPHANGITIS— ETIOLOGY,  PATHOGENESIS,  AND 
PATHOLOGY 

Predisposing  and  Active  Factors  in  the  Production  of  Lymphangitis      .  322 

Influence  of  the  Type  of  Germ 324 

Influence  of  the  Anatomy  on  the  Course 326 

Sporotrichosis 330 

Relations  of  Lymphatic  Abscesses  Studied  by  Experimental  Injections  .  331 

Report   of    Injections  of   Forearm   Near  the   Radial   and   Ulnar 

Vessels 331 

Experiments  by  Injection  along  Ulnar  Artery 333 

Pathology  of  Lymphangitis 333 

Resume -. 335 

CHAPTER  XXI 

SYMPTOMS  AND  SIGNS  OF  LYMPHANGITIS 

Symptoms  and  Signs  in  General 337 

Types 338 

Type  I.  Simple  Acute  Lymphangitis 338 

Type  II.  Acute  Lymphangitis  with  Minor  Local  Complications      .  338 
Type  III.  Acute  Lymphangitis    with    Serious    Local  Complica- 
tions    338 

Type  IV.  Acute  Lymphangitis  with  Systemic  Involvement        .      .  338 

Acute  Lymphangitis  with  Serious  Local  Complications     .      .      .      .      .  339 

Phlegmonous  Lymphangitis .341 

Frequency  of  Localization  in  Lymphatic  Infections 342 

Acute  Lymphangitis  with  Systemic  Involvement 342 

Deep  Lymphangitis 343 

Systemic  Involvement 346 

Postmortem  Statistics 352 

Thrombophlebitis 353 

Resume" 355 

CHAPTER  XXII 

PROGNOSIS  IN  LYMPHATIC  INFECTIONS 

CHAPTER  XXIII 

THE  TREATMENT  OF  LYMPHATIC  INFECTIONS— GENERAL 
DISCUSSION 

Discussion  of  Various  Procedures 361 

Local 361 

Hot,  Moist  Dressings 361 


xiv  CONTENTS 

Discussion  of  Various  Procedures:   Local — 

Rest 363 

The  Bier  Treatment 263 

Incisions 364 

Systemic  Treatment 366 

Antagonistic  Drugs 366 

Serum  and  Vaccine  Treatment 367 

Supportive  Measures 368 

Resume 369 

CHAPTER  XXIV 

THE  TREATMENT  OF  THE  COMPLICATIONS  OF 
LYMPHANGITIS 

Tenosynovitis 370 

Subcutaneous  Abscesses 372 

Periglandular  Abscesses 373 

Subclavicular  and  Shoulder  Abscesses 373 

Systemic  Complications 374 

Chronic  Infections — Repeated  Infections 374 

Resume" 382 


SECTION  IV 

ALLIED  INFECTIONS 

CHAPTER  XXV 

ERYSIPELAS,  ERYSIPELOID,  GAS-BACILLUS  INFECTION, 
ANTHRAX 

Erysipelas 383 

Erysipeloid 384 

Gas-bacillus  Infection         385 

Anthrax 390 


SECTION  V 

COMPLICATIONS  AND  SEQUELS  OF  INFECTIONS  OF  THE  HAND 

CHAPTER  XXVI 

FOREARM  INVOLVEMENT  FROM  INFECTIONS  OF  THE 
HAND— PATHOLOGY  AND  DIAGNOSIS 

Subcutaneous  Abscesses 395 

Deep  Abscesses 396 


CONTENTS  xv 

Forearm  Involvement — Abscess  Formation  without  Other  Complica- 
tion   397 

Location  of  the  Abscesses      .      .      .      .  •  . 397 

Symptoms,  Signs,  and  Diagnosis 401 

Deep  Forearm  Involvement  Associated  with  Wrist-joint  Invasion    .      .  403 

Examination  of  the  Radial  Bursa  in  Cadavers 403 

Pathology  Found  in  Serious  Wrist-joint  Involvement      ....  404 

Forearm  Involvement  with  Secondary  Hemorrhage 411 

Resume 415 

CHAPTER  XXVII 

TREATMENT    OF    INVOLVEMENT    OF    THE    FOREARM 
SECONDARY  TO  HAND  INFECTIONS 

Treatment  of  Uncomplicated  Cases 416 

Treatment  in  Cases  Where  the  Wrist- joint  is  Involved 421 

Treatment  in  Cases  of  Secondary  Hemorrhage 424 

Resume 425 

CHAPTER  XXVIII 

SEQUELS    OF    INFECTIONS    OF    THE    HAND— CHRONIC    PRO- 
CESSES, OSTEOMYELITIS,  ARTHRITIS,  CONTRACTURES, 
AND  ATROPHY 

Involvement  of  the  Finger  Proper 427 

Pathology .  .  .  . 427 

Treatment 433 

Involvement  of  the  Hand  Proper  and  the  Metacarpals  and  Carpals  .  437 

Pathology 445 

Treatment 445 

Atrophy  and  Contracture        ....'..            448 

Resume — Chronic  Infections  ......            . 453 


INFECTIONS    OF   THE    HAND. 


CHAPTER    I. 

INTRODUCTION. 
SCOPE  AND  CLASSIFICATION  OF  TYPES  OF  INFECTIONS. 

THE  accompanying  contribution  to  our  knowledge 
of  infections  of  the  hand  is  the  result  of  several  years' 
study,  comprising  experimental  and  anatomical  inves- 
tigations carried  on  in  conjunction  with  careful  clinical 
observation  of  an  extensive  number  of  cases.  In  the 
following  pages  the  diagnostic  factors  and  incisions 
which  this  work  has  suggested  will  be  described.  By 
their  use  it  has  been  possible  even  in  neglected  cases 
to  insure  a  restoration  to  complete  function  in  95  per 
cent,  of  the  abscesses  of  the  fascial  spaces;  while  in 
tendon-sheath  infections  the  morbidity  has  been 
reduced  by  fully  one-half,  and  a  greater  reduction  is 
possible  if  the  profession  as  a  whole  will  learn  to  make 
an  early  diagnosis  in  this  most  lamentable  compli- 
cation. 

HISTORY. 

Professor  Albert1  says  that  while  the  word  pana- 
ritium  was  not  used  by  Celsus,  it  is  found  in  the 
Arabian  and  other  ancient  writings,  and  appears  to 
be  a  corruption  of  the  Greek  Tra^oupd  (jiapd  ovuc). 
Paracelsus,  Dorneus,  and  others  have  used  the  words 

'Chir.,  1885,  ii. 


18  INTRODUCTION 

pandalitium,  passa,  panaris,  and  panarium,  and  it 
cannot  be  said  whether  these  refer  to  different  types 
or  are  corruptions  of  the  same  word.  Concerning  the 
elemental  meaning  of  panaritium,  Forestus1  states: 
"Panaritium  s.  Paronychia  tumor  edicitur,  calidus, 
ulcer  osus,  summe  dolor  osus,  accidens  in  summit  ate 
digitorum,  in  later e  unguis  et  quandoque  tarn  vehementer 
afficiens,  ut  vigilias  et  inquietudinem  excitet." 

Our  anatomical  knowledge  of  the  lymphatic  vessels 
dates  back  to  the  time  of  Aristotle,  but  it  is  to 
Herophilus  (300  B.  c.)  and  Herasistratus  (280  B.C.) 
to  whom,  according  to  Galenic  writings,  we  ought  to 
attribute  the  discovery  of  the  chyliferous  vessels. 
These  observations  fell  into  obscurity,  and  it  was  not 
until  1532,  when  Nicolas  Massa  discovered  renal 
lymphatics,  that  the  knowledge  of  the  subject  began 
to  grow.  Following  Eustachius,  Aselli,  and  others, 
Vessling  and  Rudbeck  in  the  seventeenth  century 
described  lymphatics  in  the  liver,  pancreas,  lungs, 
and  pelvis.  Mascagni,  Lippi,  and  Lauth  followed 
with  admirable  work,  while  Sappey,  in  1876,  published 
his  large  atlas  after  twenty  years  of  work,  when  the 
subject  can  be  said  to  have  been  put  upon  a  scientific 
basis. 

It  was  shortly  before  this  time,  however,  that  the 
study  of  lymphatic  abscesses  was  begun.  Bauchet's2 
treatise,  in  1859,  upon  infections  of  the  hand  lacked 
this  knowledge  to  make  it  a  masterpiece.  From  this 
time  until  the  culmination  of  Sappey 's  work  an  acri- 
monious discussion  was  maintained  over  the  subject 
of  lymphatic  versus  synovial  sheath  extension  of  infec- 
tion. Gosselin,  following  dissections,  adduced  proof 
that  extension  nearly  always  progressed  along  synovial 
sheaths.  Dolbeau  meanwhile  presented  a  masterly 

1  Chir.,  lib.  v,  Observat.  16. 

2  Du  Panaris,  Paris,  1859. 


HISTORY  19 

discussion,  supported  by  clinical  evidence,  in  support 
of  the  possibility  of  lymphatic  extension  with  the 
formation  of  deep  abscesses.  Chevalet,1  a  pupil  of 
Dolbeau,  chose  for  his  doctorate  thesis,  in  1875,  to 
make  a  further  contribution  to  the  literature  in  sup- 
port of  his  master's  assumptions,  bringing  to  his  aid  the 
brilliant  investigations  of  Sappey  and  others.  Later, 
Polaillon  and  Le  Dentu  supported  the  theories  of 
Gosselin,  although  the  latter  was  led  to  admit  that  the 
theories  of  Dolbeau  might  have  some  justification  in 
a  few  cases.  Since  that  time  the  subject  has  received 
little  attention,  but  we  have  gradually  come  to  assume 
that  each  party  was  too  radical  in  its  claims  and  that 
infection  can  spread  by  either  channel,  an  assumption 
that  every  clinician  has  had  occasion  to  verify. 

In  later  years  a  carefully  observed  series  of  cases 
has  been  reported  from  the  Griefswald  Clinic  by  Max 
Tornier,2  who  brought  prominently  before  the  pro- 
fession Helferich's  method  of  opening  widely  the 
sheaths,  which  was  later  substantiated  and  discussed 
with  carefully  observed  cases  by  Forssell.3 

I  wish  to  make  acknowledgment  of  abstracts  wrhich 
I  have  taken  freely  from  these  authors.  Forssell  par- 
ticularly has  written  a  most  masterly  article  upon 
tenosynovitis.  I  am  forced,  however,  to  take  issue 
with  him  as  to  certain  methods  of  treatment.  Con- 
cerning these  and  the  various  modern  ideas  as  to  the 
treatment  of  tenosynovitis,  full  reference  will  be  found 
in  the  chapter  dealing  with  that  subject. 

In  spite  of  the  fact  that  from  earliest  times  the 
importance  of  the  subject  has  been  recognized,  neither 

1  These  pour  le  doctorat  en  Medecine,  Paris,  1875. 

2  Beitrag   zur    Kenntnis    schwerer    Phlegmonen,    Inaugural    Dissertation, 
Griefswald,  1891. 

3  Klinische   Beitrage  zur   Kenntnis   der  akut   septischen   Eiterungen   der 
Sehnenscheiden  der  Hohlhand  besonders  mit  Rucksicht  auf  die  Therapie, 
Xordisches  medizinisches  Archiv,   1903,  Abt.  i,  Heft  3. 


20  INTRODUCTION 

in  text-books  nor  in  special  articles  can  the  student 
find  clear  descriptions  of  the  various  types  of  acute 
infections,  with  the  methods  of  their  diagnosis  and 
treatment.  This  I  shall  here  attempt  to  give. 

SCOPE  AND  CLASSIFICATION  OF  TYPES. 

It  is  manifest  that  if  we  are  to  have  a  clear  idea  of 
the  various  phases  of  infections  of  the  hand,  it  will  be 
necessary  to  divide  the  subject  into  various  types, 
depending  upon  the  nature  of  the  infection  and  the 
results  it  produces.  It  should  be  understood  that  we 
are  dealing  with  acute  infective  processes,  and  not 
those  associated  with  syphilis,  tuberculosis,  and  other 
chronic  infections,  although  the  general  principles  laid 
down  by  the  anatomical  and  experimental  researches 
will  be  found  to  be  applicable  there  also. 

I  have  divided  the  subject  in  general  as  follows: 

1.  Simple    localized     infections    and     allied     minor 
clinical  entities. 

2.  Grave  infections. 

(a)  Discussion    of  diagnosis   and    treatment    in 

general. 

(b)  Tenosynovitis  and   fascial  space  abscesses. 
(c}  Acute  lymphangitis  and  allied  infections. 
(d)  Complications   and  sequelae  of  acute  infec- 
tions. 

It  is  true  that  in  certain  cases  we  shall  find  all  three 
of  the  graver  types  present — i.  e.,  a  lymphangitis,  a 
tenosynovitis,  and  a  fascial  space  abscess — yet  in  a 
majority  of  cases  only  one  type  will  be  found.  If 
they  are  combined,  the  symptoms  and  signs  of  each 
are  present,  and  each  will  demand  a  separate  and 
distinct  form  of  treatment,  for  in  opening  a  synovial 
sheath  infection  wre  do  not  by  any  means  drain  the 
fascial  spaces,  nor  vice  versa.  Again,  unless  we  have 
a  clear  picture  in  our  minds  of  fascial-space  infection, 


SCOPE  AND  CLASSIFICATION  OF  TYPES  21 

and  in  a  given  case  do  not  determine  whether  or  not 
it  is  present  in  an  acute  tenosynovitis — and  the  diag- 
nosis is  by  no  means  easy — we  might  so  make  our 
incision  in  the  synovial  sheath  that  the  fascial  spaces 
would  become  infected  unnecessarily;  and  in  a  patient 
who  depends  upon  his  hands  for  his  livelihood,  such 
an  error  becomes  criminal  carelessness. 

Again,  while  a  lymphangitis  may  become  a  teno- 
synovitis or  fascial-space  infection,  in  a  great  majority 
of  cases  it  remains  a  clinical  and  pathological  entity, 
and  the  mistake  frequently  made  of  assuming  this 
relationship  and  treating  it  accordingly  has  been 
responsible  for  the  gravest  errors  and  most  serious 
consequences,  both  as  to  morbidity  and  mortality, 
that  I  have  met  in  my  experience. 

In  a  great  majority  of  cases  the  differentiation  of 
these  types  can  be  made,  but  I  know  of  no  single  rule 
by  which  it  can  be  done.  The  requisite  knowledge 
comes  only  with  a  clear  understanding  of  the  basic 
principles  of  inflammation  produced  by  the  various 
bacteria,  coupled  with  a  knowledge  of  the  anatomical 
relations  peculiar  to  the  hand  and  a  study  of  the 
course  any  given  infection  will  normally  pursue.  It 
has,  therefore,  seemed  necessary  to  give  in  some  detail 
the  anatomical  and  experimental  investigations  upon 
which  my  deductions  are  based,  rather  than  to  state 
dogmatically  the  rules  upon  which  a  diagnosis  should 
be  made  and  the  various  incisions  which  I  have  found 
to  lead  to  the  most  rapid  recovery.  If  one  will  take 
the  time  to  fix  in  mind  the  fundamental  facts  which 
are  here  discussed,  he  will  have  no  difficulty  in  apply- 
ing them  to  any  given  case.  The  technical  procedures 
incident  to  the  operations  are  easily  learned  and 
applied.  In  almost  all  cases  the  difficulty  has  been 
an  improper  diagnosis,  both  as  to  the  nature  of  the 
infection  and  the  position  of  the  pus. 


22  INTRODUCTION 

Therefore,  I  wish  to  emphasize  that  while  for  the 
sake  of  clearness  a  brief  resume  of  the  contents  has  been 
introduced  into  certain  chapters,  the  careful  surgeon 
will  find  it  necessary  to  read  the  context  for  the 
coordination  of  the  various  data. 

It  will  be  found  that  lymphatic  infections  follow  a 
distinct  anatomical  and  clinical  course,  having  at  all 
times  the  possibility  of  producing  certain  definite  com- 
plications which  may  be  prognosticated  and  -antici- 
pated. We  shall  see  that  the  tendon-sheath  infections 
pursue  definite  lines  of  invasion,  and  the  position  of 
the  pockets  of  pus  when  rupture  occurs  can  be  prog- 
nosticated, so  that  incisions  can  be  made  early  at 
these  sites  and  further  extensions  prevented. 

Concerning  the  fascial  spaces  it  will  be  shown 
that: 

(a)  There  are  certain  well-defined,  uniform  spaces 
upon  the  fingers,  palm,  and  dorsum  of  the  hand  in 
which  pus  can  accumulate. 

(&)  There  are  definite  anatomical  channels  by  which 
infection  arising  in  a  given  spot  will  extend  to  certain 
of  these  spaces,  while  certain  other  spaces  will  remain 
uninvolved;  hence  the  diagnosis  of  the  position  of  the 
pus  is  simplified  and  the  proper  site  for  the  incision 
determined. 

(c)  There  are  definite  anatomical  channels  by  which 
pus  can  spread  from  the  uniform  spaces  mentioned, 
and  when  this  occurs,  the  position  of  the  pus  can  be 
prognosticated. 

(d)  The  boundaries  of  the  fascial  spaces  having  been 
determined,  it  is  easily  seen  that  in  the  case  of  some 
of  these  the  incisions  for  evacuation  must  be  made  at 
definite  spots;  otherwise  important  structures  may  be 
injured,    or   by   ill-advised    incisions   adjacent  spaces 
may  be  opened  at  the  same  time  and  a  spread  of  the 
infection  favored  to  parts  of  the  hand  that  would  not 


SCOPE  AND  CLASSIFICATION  OF  TYPES  23 

have  become  involved  without  this  unfortunate  surgical 
procedure. 

(e)  It  can  be  understood  readily  why,  in  certain  cases, 
the  infection  has  persisted  for  weeks  and  months  after 
apparently  opening  the  pus  pocket,  since  diverticula 
and  intermediary  chambers  have  not  been  taken  into 
consideration. 

The  interrelation  of  these  various  facts  wi41  be 
emphasized  by  case  reports,  each  of  which  has  been 
introduced  to  illustrate  or  clarify  some  important 
clinical  fact.  The  number  could  have  been  multi- 
plied many  times,  but  I  have  tried  not  to  duplicate 
these  illustrations. 

We  will  return  now  to  the  slighter  infections,  such 
as  felons,  carbuncles,  paronychia,  etc.,  which  bear 
little  or  no  relation  to  these  more  serious  types  just 
considered.  It  must  be  remembered  that  they  are 
clinical  entities,  each  having  a  pathology  peculiar  to 
itself.  Owing  to  their  frequency  they  are  of  especial 
interest  to  the  practitioner.  While  the  diagnosis  is 
easily  made,  the  course  is  often  unnecessarily  pro- 
longed, owing  to  a  lack  of  appreciation  of  the  patho- 
logical anatomy  and  the  proper  means  of  treatment. 
These  types  will  be  discussed  in  the  immediately 
succeeding  chapters,  so  that  they  may  not  be  left  to 
confuse  the  student  later  while  studying  the  graver 
and  more  important  forms. 


PART   I. 

SIMPLE    LOCALIZED    INFECTIONS  AND 
ALLIED  MINOR  CLINICAL  ENTITIES. 


CHAPTER  II. 
INFECTIONS   OF   THE    DISTAL    PHALANGES. 

FELONS,  PARONYCHIA,  SUBEPITHELIAL  ABSCESSES. 

FELONS, 

FELONS  are  among  the  most  common  infections  of 
the  distal  phalanx.  The  source  may  be  a  small  pin 
prick  or  unnoticed  injury,  and  occasionally  no  history 
of  injury  may  be  elicited.  The  patient  first  notices 
a  sticking  pain  in  the  distal  phalanx,  which  rapidly 
becomes  throbbing  in  character  and  most  severe.  He 
cannot  rest  or  sleep.  The  distal  portion  of  the  finger 
becomes  red  and  swollen.  Early  it  is  tender  to  the 
touch  and  this  tenderness  is  most  marked  over  the 
site  of  the  infection.  In  the  later  stages,  after  pus 
formation  and  tissue  destruction,  the  sensitiveness  dis- 
appears. The  phalanx  is  at  first  tense  from  the  edema ; 
more  tense,  in  fact,  than  is  ordinarily  observed  with 
edema,  owing  to  the  peculiar  anatomical  structure, 
which  will  be  discussed  later.  Soon  the  tenseness  is 
replaced  by  an  induration  and  later  by  a  fluctuating, 
boggy  mass. 

The  reason  for  the  peculiar  pathological  condition 
which  is  present  here  in  localized  infection  and 


26         INFECTIONS  OF  THE  DISTAL  PHALANGES 

nowhere  else  in  the  body  is  worthy  of  consideration. 
The  ordinary  conception  of  the  pathogenesis  is  that 
which  has  been  attributed  to  Roux,  whether  justly  or 
not  I  cannot  say.  By  this  the  lymphatic  vessels  are 
supposed  to  run  perpendicularly  from  the  skin  to  the 
periosteum;  infection  thus  takes  place  under  the  peri- 
osteum, which  is  lifted  off,  and  necrosis  of  the  bone 
ensues.  Against  this  assumption  wre  have  the  very 
firm  attachment  of  the  periosteum  to  the  bone, 
Sharpey's  fibers  going  down  into  the  osseous  tissue 
in  such  a  way  that  it  is  practically  impossible  for  the 
periosteum  to  be  separated  and  differentiated  as  it  is 
elsewhere.  Moreover,  there  are  certain  anatomical 
peculiarities  which  seem  to  point  to  another  explana- 
tion of  this  frequent  change,  so  essentially  different 
from  that  noted  elsewhere  in  the  body.  The  con- 
nective-tissue framework  is  such  as  to  produce  a 
closed  sac  comprising  the  distal  part  of  the  phalanx, 
thus  differing  from  the  remainder  of  the  finger,  while 
the  glands  lying  in  the  columns  of  fat  present  a  portal 
for  the  entrance  of  pathogenic  bacteria.  This  will  be 
seen- by  examining  the  accompanying  cross  and  longi- 
tudinal sections  of  the  phalanx.  Some  of  the  glands 
may  be  seen  lying  near  the  periosteum.  Of  especial 
interest  is  the  presence  of  the  bloodvessels  which  may 
be  seen  in  the  cross-section,  one  lying  upon  either  side 
in  the  closed  space  and  running  parallel  with  the 
phalanx  (Figs.  I  and  2}.  Should  pus,  or  edema  the 
result  of  infection,  develop  to  an  undue  degree  in 
this  closed  space,  it  would  have  no  means  of  free 
egress  as  in  the  other  connective-tissue  space.  Hence 
it  would  have  a  tendency  to  shut  off  the  blood  supply 
and  cause  necrosis  of  the  bone.  It  will  be  seen  by 
examining  the  longitudinal  section  that  the  portion 
of  the  bone  involved  is  the  diaphysis,  since  the  epiphy- 
sis  receives  its  blood  supply  before  the  vessel  enters 


FELONS 


27 


the  closed  space.     Anatomically,  then,  we  expect  the 
epiphysis  to  escape  necrosis  in  these  cases,  and  clinical 


FIG.  i 

Bloodvessel. 


Transverse  section  of  distal  phalanx,  showing  the  closed  pocket  with  columns 
of  fat  radiating  from  the  bone.  The  glands  are  well  shown  and  demonstrate 
how  easy  it  would  be  for  pathogenic  organisms  to  invade  this  space  through 
these  glands. 


28         INFECTIONS  OF  THE  DISTAL  PHALANGES 

observation  corroborates  this  view,  since  the  diaphysis 
is  the  part  of  the  bone  which  is  lost.  This  finds  its  most 
perfect  example  in  children  and  those  whose  epiphyses 
and  diaphyses  have  not  progressed  to  perfect  bony 
union.  It  has  been  my  experience  frequently  to  open 
these  old  felons  in  children  and  have  the  diaphysis 
fall  out  of  the  sac,  where  it  has  been  floating,  a  free 
body,  in  a  sea  of  pus.  In  adults,  where  osseous  union 

FIG.  2 


Longitudinal  section  of  the  distal  phalanx  and  articulation.  Note  the 
closed  pocket  of  the  pulp  of  the  finger  and  the  columns  of  fat,  with  glands 
shown  as  dark  dots  spread  throughout.  Note  that  the  epiphysis  is  well 
separated  from  this  pocket. 

has  taken  place,  an  examination  will  show  the  necrotic 
diaphysis  standing  out  free  from  the  surrounding 
tissue,  with  the  epiphysis  and  joint,  in  the  early 
stages  at  least,  practically  untouched  by  the  destruc- 
tive process. 

This  explanation  of  the  pathological  sequence  would 
seem  to  be  more  reasonable  than  that  of  Roux,  and 
also  explains  the  rapid  recession  of  the  process  after 
an  early  opening,  and  the  slow  recovery  when  delay 


FELONS  29 

has  permitted  the  disease  to  destroy  the  connec- 
tive tissue  which  must  ultimately  be  expelled  as  a 
slough. 

When  the  incision  has  been  delayed  or  the  process 
permitted  to  go  on  to  spontaneous  expulsion  of  the 
necrotic  matter,  we  find  a  bluish  insensitive  pus  £>ag 
with  a  sinus  opening  which  frequently  appears  at  one 
side  near  the  nail.  As  a  rule,  the  granulation  tissue 
is  not  excessive,  the  sinus  appearing  more  as  a  simple 
canal  uniting  the  pus  pocket  with  the  exterior.  Frag- 
ments of  seminecrotic  connective  tissue  often  appear 
partially  plugging  the  opening. 

TREATMENT.— The  treatment  of  felons  consists  in 
immediate  incision  into  the  infected  area. 

Certain  errors  are  seen  at  times.  The  first  is  an 
incision  made  into  a  phalanx  in  which  there  is  a  begin- 
ning lymphangitis  and  not  a  localization  in  the  distal 
phalanx.  Such  infections  cause  pain  and  tenderness 
throughout  the  whole  finger,  although  most  marked 
in  the  distal  phalanx.  Again,  the  edema  is  more 
general,  not  having  the  excessive  tenseness  in  the  pulp 
of  the  finger  characteristic  of  a  beginning  felon.  In- 
cision here  is  not  only  unnecessary,  but  positively 
harmful,  as  will  be  brought  out  in  discussing  the  sub- 
ject of  lymphangitis  as  a  whole. 

The  second  error  consists  in  waiting  until  fluctuation 
has  begun.  If  this  is  done,  unnecessary  pain  is  endured 
by  the  patient.  Moreover,  such  destruction  of  the 
connective  tissue,  and  even  of  the  bone,  has  occurred 
as  to  cause  not  alone  prolonged  convalescence,  but 
even  permanent  deformity.  The  incision  should  be 
made  as  soon  as  the  edema  restricted  to  the  distal 
phalanx  has  proceeded  to  a  degree  causing  a  hardness, 
but  not  necessarily  the  board-like  feeling  characteristic 
of  pus  in  other  subcutaneous  areas.  In  general,  one 
may  say  that  when  there  is  present  a  painful,  tender, 


30         INFECTIONS  OF  THE  DISTAL  PHALANGES 

distal  phalanx,  with  excessive  edema  limited  to  the 
phalanx,  incision  should  be  made. 

Generally  the  patient  comes  for  treatment  after  the 
whole  area  is  involved,  but  at  times  the  finger  will  be 
seen  early  enough  to  decide,  because  of  the  localized 
tenderness,  that  the  pus  has  not  extended  throughout 
the  whole  of  the  closed  space,  in  which  case  the  inci- 
sion should  be  made  over  the  localized  tender  area. 
In  those  cases  in  which  there  is  no  localization,  but 
the  whole  phalanx  seems  involved,  the  incision  should 
be  made  somewhat  to  the  side,  and  not  in  the  median 
line,  as  is  unfortunately  frequently  done.  The  median 
incision  leaves  a  scar  over  the  site  of  the  tactile  por- 
tion of  the  finger,  so  that  the  more  delicate  functions 
of  that  part  may  be  impaired.  By  examining  the  cross- 
sections  here  shown  it  will  be  seen  that  this  pocket  can 
be  opened  by  a  lateral  incision  just  as  satisfactorily 
as  by  a  median  one,  and,  in  fact,  somewhat  better, 
since  the  radiating  columns  of  fat  and  connective 
tissue  will  be  cut  transversely,  thus  leading  to  more 
satisfactory  drainage.  If  the  incision  is  made  early, 
one  is  often  surprised  at  the  rapidity  of  the  recovery. 

In  those  cases  in  which  incision  has  been  delayed 
until  necrosis  has  ensued,  certain  phenomena  may  be 
observed.  The  connective  tissue  of  the  pulp  may 
be  so  destroyed  that  pus  will  continue  to  discharge 
until  the  slough  of  seminecrotic  tissue  is  expelled.  If 
the  opening  is  small,  recovery  may  be  hastened  by  re- 
moving the  detritus  with  tissue  forceps.  Its  removal, 
however,  must  await  the  natural  pathological  processes 
incident  to  all  separation  of  necrotic  from  living  tissue. 

Again,  when  the  bone  is  involved  the  question  often 
arises  as  to  what  disposition  to  make  of  it.  This  will 
vary  with  the  amount  of  involvement.  If  there  is 
complete  separation  of  the  tissues  from  the  diaphysis, 
so  that  it  stands  out  free  like  a  telegraph  pole  in 


PARONYCHIA  31 

the  pus,  it  should *be  removed  at  once  by  the  bone- 
cutting  forceps,  remembering  that  the  epiphysis  is 
not  involved.  In  the  case  of  a  child  the  diaphysis 
is  often  separated  at  the  time  of  incision  or  can  be 
easily  cut  off  with  the  scissors  because  of  the  lack  of 
bony  union  between  the  epiphysis  and  diaphysis.  If 
the  bone  is  exposed  upon  only  part  of  its  circumference 
it  will  frequently  heal  without  further  trouble  and 
should  be  treated  conservatively.  In  those  cases  in 
which  the  diaphysis  is  removed  no  disability  of  the 
joint  need  be  feared  unless  it  has  become  involved,  a 
complication  occurring  only  in  a  few  instances.  The 
phalanx  will  be  somewhat  short  and  the  ringer  nail 
may  be  deformed,  but  movement  will  not  be  seriously 
impaired. 

The  after-treatment  is  the  same  as  that  used  after 
any  incision  in  acutely  infected  areas,  consisting 
essentially  in  procedures  designed  to  relieve  pain  and 
favor  walling-off  of  the  process  by  round-celled  infil- 
tration. Locally  nothing  is  superior  to  the  ordinary 
dressing  saturated  with  hot  boric  acid  solution  until 
the  acuteness  of  the  inflammation  subsides.  The  hand 
is  elevated  to  lessen  the  throbbing  pain.  These  meas- 
ures are  supplemented  by  opiates  if  necessary.  After 
the  acute  inflammation  subsides  the  finger  is  dressed 
by  gauze  thoroughly  saturated  writh  vaseline,  which 
permits  the  free  escape  of  pus  and  allows  the  removal 
of  the  dressings  without  pain  to  the  patient. 

PARONYCHIA. 

Among  the  infections  of  the  distal  phalanx,  is  none 
apparently  so  simple  as  the  paronychia,  or  "run- 
arounds, "  and  yet  they  frequently  baffle  treatment 
for  some  weeks,  since  the  pathology  may  not  be  under- 
stood. They  begin  ordinarily  at  one  side  of  the  nail 
as  a  simple  infection,  frequently  from  a  "hangnail." 


32          INFECTIONS  OF  THE  DISTAL  PHALANGES 

This  infection  may  be  of  two  types:  first,  an  acute 
infection,  giving  rise  to  a  small  wheat-grain-sized 
abscess  in  the  subepithelial  tissue  at  the  side  of  the 
nail,  which,  if  opened,  makes  an  immediate  recovery; 
if  neglected,  it  spreads  along  the  side  of  the  nail  and 
back  to  the  base,  becoming  secondarily  a  typical 
"run-around. "  More  often,  however,  this  chronic  type 
develops  from  a  chronic  infection  along  the  edge  of 
a  "hangnail."  For  a  number  of  days  a  drop  of  pus 
or  more  will  exude  from  the  inflamed  area  about  the 
nail  edge.  It  will  then  be  noticed  that  on  the  same  side 
at  the  base  there  is  a  certain  amount  of  swelling  and 
redness,  with  little  or  no  pain.  As  the  days  pass  the 
swelling  and  redness  gradually  extend  about  the  base 
of  the  nail  until  the  opposite  side  is  reached.  At  the 
end  of  two  or  three  weeks  drops  of  pus  will  be  expressed 
from  under  various  parts  of  the  overlying  epithelium 
(eponychium).  A  week  or  two  later  the  entire  nail 
may  be  lifted  off  the  matrix  and  cast  off,  or  at  least 
detached  along  its  entire  base.  Meanwhile,  a  chronic 
discharge  of  pus  continues  from  the  original  nail 
sulcus  from  under  the  eponychium,  since  the  swelling 
and  edema  do  not  favor  satisfactory  drainage.  This 
continues  for  some  time,  during  which  the  matrix 
begins  to  proliferate  freely  and  an  almost  fungus-like 
elevation  of  granulation  tissue  appears  growing  from 
underneath  the  overhanging  cuticle.  This  picture  of 
the  neglected  case  is  not  at  all  uncommon,  owing  to 
the  habit  of  the  patients  to  consider  this  infection  as 
unimportant  and  consequently  to  treat  it  by  poultices 
and  salves.  In  this  they  are  often  abetted  by  the  ill- 
informed  physician.  At  times,  it  is  true,  spontaneous 
recovery  may  take  place,  but  most  often  the  nail  is 
lost  after  a  more  or  less  prolonged  course. 

Let  us  consider  the  pathology  of  these  chronic 
inflammations  when  they  spread  to  the  base  of  the 


PARONYCHIA  33 

nail.  It  will  almost  always  be  found  that  the  pus  is 
under  the  overhanging  edge  of  the  nail.  Upon  exten- 
sion the  pus  follows  around  the  nail  sulcus,  still  under 
the  nail.  The  soft  and  delicate  nail  root,  under  the 
eponychium,  is  raised  entirely  off  of  the  nail  bed, 
although  the  distal  exposed  portion  of  the  nail  is  still 
firmly  attached  to  the  matrix. 

TREATMENT. — With  a  clear  understanding  of  the 
above  pathology,  it  is.  manifest  that  the  only  proper 
procedure  is  to  allow  escape  of  this .  imprisoned  pus. 
This  is  done  by  making  a  longitudinal  incision  along 
the  outer  edge  of  the  nail,  going  back  to  the  base  as  far 
as  the  sulcus,  with  especial  care,  let  me  repeat,  to  cut  to 
the  outer  side  of  the  nail  so  as  not  to  cut  the  nail  bed 
or  the  overhanging  cuticle,  since  if  this  is  done  it  may 
result  in  a  permanently  split  nail  when  it  grows  out 
anewr.  The  eponychium  is  now  pushed  back  with  a 
sponge  and  the  point  of  a  sharp  scissors  inserted  under 
the  detached  edge  of  the  nail  and  this  is  cut  off,  together 
with  as  much  of  the  root  of  the  nail  as  had  become 
separated  from  the  matrix  by  the  pus.  It  is  wise, 
generally,  to  be  on  the  side  of  radicalism,  since  otherwise 
secondary  operations  may  become  necessary.  After 
removing  this  portion  of  the  nail  the  elevated  flap 
of  overhanging  cuticle  is  packed  up  and  out  of  the 
field  by  a  small  strip  of  gauze  saturated  with  vaseline 
to  favor  drainage  for  a  few  days.  A  hot,  moist  dressing 
is  applied  to  the  entire  finger  for  a  couple  of  days,  after 
which  time  a  vaseline  gauze  dressing  or  dry  dressing 
is  applied  as  the  case  may  demand. 

Concerning  those  cases  in  which  more  than  half 
of  the  base  has  become  involved  in  the  swelling  and 
redness,  a  wrord  further  is  required.  Here  a  second 
incision  should  be  made  upon  the  other  side  of  the 
nail,  using  the  same  precaution  as  in  the  first  incision, 
not  to  cut  the  nail  bed  or  the  overhanging  cuticle 

3 


34 


INFECTIONS  OF  THE  DISTAL  PHALANGES 


(Fig.  3).    The  eponychium  which  is  now  entirely  sepa- 
rated from  the  epithelium  on  its  two  sides  is  pressed 


FIG.  3 


Lines  of  incision  used  in  paronychia. 
FIG.  4 


Photograph  of  steps  of  operation  in  paronychia.     Flap  has  been  raised  and 
the  point  of  the  scissors  inserted  under  the  base  of  the  nail. 

back  and  elevated  as  before,  exposing  the  entire  sulcus. 
The  loosened  portion  of  the  nail  in  these  cases  will 


PARONYCHIA 


35 


often  comprise  the  entire  nail  root.  This  is  completely 
removed,  leaving  the  distal  portion  of  the  nail  still 
attached  to  the  matrix.  Gauze  is  packed  in,  as  before, 
to  raise  the  flap  and  secure  drainage  (Fig.  4). 

It  is  not  necessary  to  remove  the  distal  portion  if 
it  is  not  already  detached.  It  does  not  interfere  at  all 
with  recovery,  and  is  still  of  some  service  after  the 


FIG.  5 


Untreated  paronychia. 

acute  inflammation  at  the  base  subsides.  The  new 
nail  rapidly  forms,  and  in  growing  out  pushes  the  old 
nail  in  front  of  it  (Figs.  5,  6,  and  7). 

In  those  cases  in  which  the  condition  has  been 
neglected  or  in  which  the  liberating  incisions  have  not 
been  made  at  the  sides,  a  considerable  cauliflower-like 
growth  of  granulations  may  appear,  as  has  already  been 
mentioned.  This  is,  of  course,  due  to  the  irritation 


36         INFECTIONS  OF  THE  DISTAL  PHALANGES 

FIG.  6 


All  inflammation  has  subsided  and  new  nail  is  growing  out,  forcing  the  old 

remnant  off. 

FIG.  7. 


Complete  recovery  at  the  end  of  seven  weeks. 


SUBEPITHELIAL  ABSCESSES  37 

incident  to  inadequate  drainage.  Hence  we  should  see 
that  the  drainage  is  free.  This  will  be  followed  by  the 
formation  of  nail  and  the  rapid  disappearance  of  the 
granulations.  I  have  never  yet  cauterized  these.  In 
one  intractable  case  rapid  relief  was  secured  by  placing 
a  rubber  band  about  the  base  of  the  finger,  producing  a 
Bier's  hyperemia  for  some  days. 

SUBEPITHELIAL  ABSCESSES. 

It  is  not  at  all  uncommon  for  subepithelial  infections 
to  take  place  either  as  local  processes  or  associated 
with  more  extensive  infections.  The  epithelium  may 
be  raised  over  a  considerable  area,  both  upon  the  flexor 
and  the  extensor  surfaces.  This  kind  of  infection  is 
frequently  seen  as  a  local  process  about  the  distal 
phalanx,  the  contents  being  generally  a  seropurulent 
fluid  of  low  grade  of  virulency. 

The  treatment  consists  in  removing  the  elevated 
epithelial  covering  and  applying  some  dry  dressing  or 
hot  boric  dressing  as  the  virulency  of  the  case  demands. 
It  is  essential  that  every  part  of  the  detached  epithe- 
lium be  removed,  otherwise  the  moist,  warm  pocket 
will  favor  the  further  development  of  the  infection. 


CHAPTER   III. 
CARBUNCULAR  INFECTIONS. 

THE  carbuncles  which  develop  on  the  hand  are 
typical  of  that  condition  elsewhere.  Carbuncles,  al- 
though seen  frequently,  are  often  not  understood  by 
the  practitioner,  who  does  not  take  the  proper  steps 
necessary  to  their  immediate  cure. 

They  may  develop  in  any  portion  of  the  dorsum 
containing  hair  follicles,  their  most  common  site,  there- 
fore, being  the  dorsum  of  the  proximal  phalanges 
(Figs,  ii  and  12)  and  the  back  of  the  hand  upon  the 
ulnar  side.  The  various  types  of  staphylococci  are 
most  often  the  exciting  organisms.  The  peculiar 
pathology  characteristic  of  this  condition  is  due  to 
the  nature  of  the  skin  and  subcutaneous  tissue  with 
its  sweat  glands,  hair  follicles,  and  columns  of  fat 
extending  up  into  the  derma. 

ANATOMICAL  CONSIDERATIONS  AND  PATHOGENESIS. 
—In  an  attempt  to  determine  the  source  of  these 
infections  and  the  cause  of  their  persistence,  I  made 
serial  sections  of  a  portion  of  the  skin  and  identified 
the  various  structures  in  the  succeeding  sections,  with- 
out, however,  being  able  to  say  definitely  that  the 
source  could  be  attributed  to  either  the  sweat  glands 
or  hair  follicles  alone.  Repeatedly  on  examination  a 
hair  follicle  with  its  sebaceous  gland  could  be  found  in 
the  subjacent  columnae  adiposse;  on  the  other  hand, 
it  almost  as  frequently  occurred  that  the  convoluted 
sweat  gland  would  also  be  found  (Figs.  8  and  9).  One 
could  only  conclude,  therefore,  that  it  was  possible 
for  the  carbuncle  to  begin  from  either,  although  it 


ANATOMICAL  CONSIDERATIONS  AND  PATHOGEN  ESI  S  39 

seemed  more  reasonable  to  attribute  its  source  to  the 
hair  and  its  sebaceous  gland.  Garre,  Budinger,  and 
others  have  demonstrated  upon  themselves  that  it  is 
very  easy  to  produce  such  infections  by  rubbing  into 
the  skin  virulent  streptococcus  cultures. 


Sit'eat 
Gland 


Sagittal  section  of  the  skin  showing  columna  adiposa.  At  the  upper  part 
note  the  hair  follicle  with  its  sebaceous  glands  connecting  this  column  of 
fat  with  the  skin.  In  the  lower  portion  of  the  column  of  fat  a  sweat  gland 
is  seen. 

In  the  accompanying  microscopic  illustration  of  a 
cross-section  of  the  skin,  the  various  columnae  adiposse 
may  be  seen  with  the  hair  follicles,  sebaceous  glands, 
and  sweat  glands  in  various  locations  (Fig.  10).  From 
a  study  of  this,  the  course  an  infection  will  pursue  can 
be  seen  readily.  Beginning  in  one  of  the  columnae, 


40 


CA  RB  UNC  ULA  R  INFECTIONS 


the  accumulation  finds  readier  escape  downward  into 
the  subjacent  fat.  From  there  it  spreads  laterally  and 
gradually  fills  the  loose  mesh  under  the  skin  and  ascend 
into  the  various  columnar,  from  whence  the  infection 
extends  to  the  surface  from  these  many  sources,  strain- 
ing through  a  sieve,  as  it  were.  As  the  process  persists 
the  central  part  of  the  surface  becomes  necrotic,  and 

FIG.  9 


Section  parallel  to  the  skin.  Note  that  here  we  have  two  columnae  adi- 
posae  cut  transversely.  In  one  a  hair  is  seen  and  in  the  other  a  hair  and  a 
sweat  gland.  It  is  readily  seen  how  pus  would  follow  along  these  to  the 
surface. 

through  this  is  extruded  pus  and  seminecrotic  connec- 
tive tissue.  Even  this  does  not  give  free  drainage,  and 
the  process  still  tends  to  extend  around  the  periphery. 
Meanwhile,  more  and  more  of  the  overhanging  skin 
becomes  destroyed,  until  such  time  as  enough  sur- 
face is  destroyed  to  give  free  exit  to  the  pus  and 
the  surrounding  inflammatory  infiltration  walls  off  the 
infection,  which  it  does  with  difficulty,  owing  to  the 


ANATOMICAL  CONSIDERATIONS  AND  PATHOGEN  ESI  S  41 

many  interstices  in  the  loose  mesh  of  subcutaneous 
tissue  through  which  the  pus  can  extend.  An  exami- 
nation of  a  schematic  cross-section  of  such  an  inflamed 
area  shows  these  various  facts.  Clinically  they  are 

FIG.  10 


A  section  of  the  skin,  subcutaneous  tissue,  and  muscle,  showing  the  area 
in  which  the  pus  of  a  carbuncle  develops  and  how  it  spreads  beneath  the  skin 
and  comes  to  the  surface  through  the  various  dark  lines  in  the  skin  which 
represent  the  hair  follicles.  Note  several  dark  dots  (H)  in  the  fat  under- 
neath the  skin.  These  are  cross-sections  of  hairs  which  have  penetrated 
beneath  the  skin  and  lie  in  the  fat. 


42 


CARBUNCULAR  INFECTIONS 


observed  on  the  surface  as  follows:  First,  the  central 
necrotic  area:  about  this  the  area  of  tissue  shows 
punctate  pus  exudations,  and  beyond  this  a  bluish 
circumference  through  which  the  pus  has  not  pene- 
trated, although  it  is  under  the  skin,  and,  finally, 
surrounding  it  all,  an  area  of  induration  denoting 
inflammatory  reaction. 

FIG.  ii 


«.  v\,. 


Schematic  drawing  showing  the  areas  of  the  carbuncle  with  the  length  of 
incisions  upon  the  skin. 

TREATMENT. — These  cases  are  best  treated  by  a 
crucial  incision,  the  ends  of  which  extend  beyond  the 
•edge  of  infiltration,  followed  by  incisions  under  the 
skin,  so  that  this  may  be  raised  off  of  the  underlying 


TREATMENT 


43 


tissue  (Figs,  n  and  12).    The  base  of  the  flaps  should 
correspond    with    the    ends    of    the    crucial    incisions. 


FIG.  12 


Schematic  drawing  showing  areas  of  infection  in  the  carbuncle  and  the 
method  by  which,  through  a  transverse  incision  parallel  to  the  skin,  the 
flaps  are  raised  up.  Note  that  this  incision  F  goes  to  the  limit  of  the  area 
of  induration  A;  B,  area  of  round-celled  infiltration  and  some  pus;  C,  area 
of  pus,  most  of  the  fat  being  destroyed;  D,  area  of  necrosis. 

Hot,  moist  gauze  is  now  packed  under  the  flaps  to 
insure  drainage.  The  patients  are  always  anesthe- 
tized, nitrous  oxide  being  preferable.  The  reasons 


44  CARBUNCULAR  INFECTIONS 

for  carrying  the  incisions  in  the  skin  beyond  the  edge 
of  inflammatory  exudation,  as  indicated  by  the  in- 
duration, are  difficult  to  understand.  The  principle 
is  directly  opposed  to  the  ordinary  conception  of 
this  area  as  a  protecting  wall,  which  in  other  con- 
ditions we  would  use  every  possible  precaution  to 
preserve.  Of  the  advisability  of  the  length,  however, 
I  have  no  doubt,  since  I  have  had  occasion  to  use  this 
method  in  probably  30  cases,  and  whenever  the  tech- 
nique described  has  been  faithfully  carried  out  the  result 
has  always  been  satisfactory.  If,  however,  through  a 
conservatism  I  fell  short,  the  extension  always  took 
place  along  that  area,  while  the  sides  where  I  had  made 
the  long  incisions  would  go  on  to  satisfactory  recovery. 
This  same  holds  true  for  carbuncles  of  the  neck  and 
other  areas. 

The  cuts  parallel  to  the  skin  designed  to  free  the 
skin  from  the  deep  fascia  should  be  made  about  mid- 
way between  these  two  layers,  going  back  through  the 
area  of  induration  also  (Fig.  12).  Any  arterial  bleeding 
is  stopped,  but  the  venous  oozing  is  controlled  by  pack- 
ing, and  this  packing  should  be  sufficient  to  raise  the 
flaps  well  up.  The  packing  is  removed  at  the  end  of 
twenty-four  hours,  and  the  flaps  allowed  to  fall  back. 
If  there  is  not  much  venous  oozing,  the  gauze  is  thor- 
oughly saturated  with  vaseline,  which  allows  drainage 
and  permits  removal  without  pain  to  the  patient. 

If  there  is  any  free  slough  it  is  removed  at  the  time 
of  operation.  It  is  not  necessary  to  curette  or  cut 
away  any  tissue  whatever.  The  removal  of  any  of  the 
skin,  no  matter  how  much  damaged  and  fragmentary, 
should  be  condemned,  since  one  is  always  surprised 
at  the  rejuvenation  of  apparently  hopelessly  injured 
skin.  I  have  often  found  the  flaps  to  fall  into  place 
and  leave  a  granulating  area  no  larger  than  a  dime, 
where  it  had  seemed  the  entire  area  must  be  lost.  For 


TREATMENT  45 

that  reason  also  one  should  condemn  most  severely 
the  procedure  advocated  by  some  of  excising  the  entire 
area.  On  the  other  hand,  the  crucial  incision  alone, 
without  raising  the  flaps,  is  futile  in  almost  all  cases, 
and  certainly  prolongs  convalescence. 

CASE  I. — In  this  connection  the  history  of  a  patient 
sent  me  for  treatment  is  interesting.  When  the  patient 
was  first  seen  he  had  been  suffering  for  three  weeks  with 
a  carbuncle  on  the  dorsum  of  the  left  hand.  It  had 
begun  as  a  small  pimple  on  the  ulnar  side,  and  incisions 
had  been  made  on  six  different  occasions  at  different 
points.  The  infection  had  spread  to  involve  the  entire 
dorsum,  and  had  extended  to  the  flexor  surface  around 
the  thumb  and  the  wrist  at  the  ulnar  side.  The  slough- 
ing connective  tissue  was  being  extruded  from  the  in- 
cisions and  small  necrotic  ostea  which  had  appeared  over 
its  surface.  In  other  places  ii  had  the  characteristic 
appearance  of  a  carbuncle. 

The  patient  was  anesthetized  and  a  crucial  incision 
made,  not,  however,  carrying  the  incision  the  full  length 
of  the  infected  area,  for  fear  of  impairing  the  nutrition 
of  the  flaps.  The  entire  area,  however,  was  undermined 
and  gauze  saturated  with  hot  boric  acid  solution  carried 
to  the  edge.  An  immediate  cessation  of  the  process 
took  place  except  at  the  wrist,  where  a  subsequent 
incision  had  to  be  made,  owing  to  the  inadequacy  of  the 
early  incision.  When  the  flaps  finally  healed,  it  was 
found  that  no  grafting  was  necessary.  So  much  of  the 
skin  had  retained  its  vitality  that  the  denuded  areas 
were  soon  covered  by  epithelium. 

At  times  I  have  been  compelled  to  cover  a  small 
denudation  by  a  Thiersch  graft  from  the  patient's 
body.  This  should  be  done  as  soon  as  a  good  granu- 
lating base  has  been  assured.  This,  in  my  experience, 
is  more  often  necessary  on  the  dorsum  of  the  finger 
than  on  the  back  of  the  hand. 

The  illustrations  show,  in  both  cases,  beginning 
carbuncles  (Figs.  13  and  14).  The  one  on  the  finger 


4G 


CARBUNCULAR  INFECTIONS 


had   been   treated   a  week  before   it  came   under  my 
observation,    and,    after    incision,    was    dressed    only 


FIG.  13 


Beginning  carbuncle  on  the  ulnar  side  of  the  dorsum  of  the  hand. 

FIG.  14 


Carbuncle  on  the  dorsum  of  the  proximal  phalanx. 

twice  and  was  entirely  well  in  a  week.    The  one  on  the 
dorsum  of  the  hand   had   been   treated   for  six  days 


DIFFERENTIAL  DIAGNOSIS  47 

after  a  simple  incision.  After  opening  it  properly  and 
applying  the  Bier  suction  cup,  which  I  have  at  times 
used  with  success,  entire  healing  followed  in  a  week. 
This  picture  of  an  apparently  simple  case  is  presented, 
since  it  is  in  such  that  the  diagnosis  is  not  made.  They 
are  considered  simple  abscesses.  The  more  severe 
cases  with  the  punctate  areas  of  pus,  if  they  are 
acute,  are  recognized  by  all. 

DIFFERENTIAL  DIAGNOSIS. — Oidiomy costs. — There  is 
a  more  chronic  type  of  infection  of  this  area  which 
may  be  mistaken  for  oidiomycosis  (blastomycosis), 
and,  conversely,  an  oidiomycosis  may  be  construed  to 
be  a  subacute  carbuncle.  The  appearance  of  these 
oidiomycotic  areas  is  very  characteristic,  presenting  a 
rather  clean  granulating  surface,  while  the  edge  which 
is  undermined  appears  as  if  moth-eaten,  with  pus  drop- 
lets exuding  through.  In  some  parts  the  process  will 
apparently  have  healed  and  be  covered  by  a  thin, 
shining  sheet  of  epithelium.  Over  the  granulating  area 
the  skin  is  not  completely  destroyed,  since  areas  of 
epithelium  remain  which  rapidly  produce  epidermiza- 
tion  when  the  process  is  halted. 

The  diagnosis  can  be  made  readily  by  securing  pus 
from  the  abscess  and  examining  the  unstained  smear 
diluted  with  4  per  cent.  KOH,  or  with  normal  salt 
solution.  This  finding  may  be  corroborated  by  micro- 
scopic examination  of  the  skin,  which  will  show  the 
proliferating  rete  with  miliary  abscesses. 

One  such  case  came  under  my  care  in  which  the 
condition  had  been  held  to  be  a  chronic  infection  and 
had  been  treated  with  salves  and  applications  until 
the  entire  dorsum  was  covered  by  the  ulcerated  area. 
The  edges  were  curetted  thoroughly  and  potassium 
iodide  given  in  large  doses  (400  grains  per  day).  The 
lesion  finally  healed  after  some  weeks,  during  which 
it  was  necessary  to  remove  the  extending  edge  in 


48  CARBUNCULAR  INFECTIONS 

various  parts  several  times.  Unfortunately,  I  have 
not  a  photograph  of  the  lesion,  but  it  was  practically 
identical  with  that  shewn  by  the  photograph  (kindly 
loaned  me  by  Dr.  Ormsby)  of  the  same  condition  in 
a  patient  of  his  (Fig.  15). 

FIG.   15 


Oidiomycosis.   (Photograph  loaned  by  Dr.  Ormsby.)    Typical  and  practically 
identical  with  that  seen  in  Case  II. 


CASE  II. — Mr.  G.  C.,  of  Gallion,  Ohio,  was  referred 
to  me  with  the  history  that  seven  months  before  he 
noticed  a  small  pimple  on  the  dorsum  of  the  right  hand. 
The  patient  opened  the  pimple  with  scissors,  following 
which  the  sore  began  to  spread  by  peripheral  extension. 
A  couple  of  weeks  later  a  similar  lesion  began  on  the 
neck,  as  a  result  of  the  patient  scratching  a  pimple  there. 
These  two  lesions  continued  to  spread  until  about  three 
weeks  before  I  saw  the  patient,  when  two  small  pustules 
appeared  upon  the  right  arm,  and  since  that  several  small 
lesions  had  appeared  on  the  trunk,  all  possibly  implanted 
through  self-contamination  by  scratching.  The  lesion  on 
the  hand  was  of  approximately  the  size  shown  in  the 
illustration.  That  upon  the  neck  was  about  one  and 
one-half  inches  in  diameter.  The  characteristic  appear- 
ance already  described  was  present.  The  areas  were 


DIFFERENTIAL  DIAGNOSIS 


49 


excised,  following  which  all  the  lesions  disappeared  except 
that  upon  the  hand.  This  also  finally  disappeared  under 
curettage  and  large  doses  of  potassium  iodide. 

The  condition  is  essentially  different  from  the 
picture  presented  by  the  foul  sloughing  syphilitic 
ulcer  or  the  blue  undermined  tuberculous  process. 

Chronic  Staphylococcus  Processes. — We  may  have  a 
chronic  Staphylococcus  process  upon  the  dorsum,  as 

FIG.  i 6 


Chronic   Staphylococcus   infection  of   the   dorsum   simulating   oidiomycosis. 

(See  Case  III.) 

has  already  been  said,  which  may  be  wrongfully  diag- 
nosticated as  oidiomycosis.  Such  a  case  came  under 
my  observation  with  an  ulceration  upon  the  dorsum 
which  had  involved  during  its  course  a  greater  part 
of  the  area,  some  parts,  however,  showing  pinkish, 
glistening  new  epidermis,  while  others  showed  active 
process  appearing  as  an  ulcerating  granulating  surface, 

4 


50  CARBUNCULAR  INFECTIONS 

or  rather  as  a  depressed  verrucous  process,  while  the 
edges  of  these  areas  showed  the  advancing  border  of 
infection.  Repeated  examinations,  both  by  culture  and 
microscopic  tissue  study,  demonstrated  a  pure  culture 
of  staphylococcus.  It  is  my  belief  that  the  process 
had  become  chronic  in  its  nature,  owing  to  the  peculiar 
anatomy  I  have  described  as  being  found  here,  coupled 
with  lowered  resistance  to  the  specific  organism  and  the 
irritation  of  the  various  treatments  to  which  it  had 
been  subjected.  It  healed  rapidly  under  bland,  slightly 
antiseptic  applications.  It  is  my  opinion  that  a  passive 
hyperemia  produced  by  local  suction  cups  would  also 
have  hastened  recovery  in  this  case.  An  autogenous 
vaccine  might  also  have  helped.  The  case  history, 
written  by  the  patient,  who  was  a  physician,  is  ap- 
pended. The  photograph  (Fig.  16)  shows  the  condition 
inadequately. 

CASE  III. — "Family  history  negative;  aged  forty-four 
years;  good  health.  On  September  12,  1910,  I  noticed 
skin  on  middle  knuckle  of  right  hand,  flecked  up  as  if 
by  a  pin.  On  the  morning  of  the  I5th  I  noticed  some 
reddening  of  the  knuckle  extending  up  into  the  back 
of  the  hand,  with  a  slight  burning  pain.  On  the  morn- 
ing of  the  1 6th  my  hand  was  badly  swollen.  Pain  very 
severe  when  hand  hung  down,  and  burning  was  intense. 

"I  treated  it  vigorously  with  wet  dressings  of  bichlo- 
ride, carbolic  acid,  and  boric  acid  alternately.  The 
swelling  subsided  in  a  few  days.  The  pain  was  not  so 
severe,  but  the  burning  sensation  continued.  The 
place  where  the  infection  started  broke  down,  forming 
something  like  a  small  ulcer.  The  infection  then 
seemed  to  extend  up  the  back  of  my  hand.  Every 
hair  follicle  seemed  to  be  a  centre  of  infection,  breaking 
down  and  forming  a  small  opening  from  which  exuded 
pus.  I  treated  it  with  iodine,  carbolic  acid,  ointments 
of  every  description,  dry  and  wet  dressings.  With  all 
the  treatment  the  infection  continued  to  spread  over 
the  back  of  the  hand,  with  more  or  less  pain  all  the 


LlGFf-F'f  OF 


_          r     r  r  ,,  r    r 
DIFFERENTIA  L  DlA  GNOSTS  '  ^  #£ 

time,  but  increasing  at  intervals,  the  burning  being 
almost  continuous. 

"On  December  25,  1910,  becoming  disgusted  with  my 
own  treatment,  and  upon  advice  of  my  neighboring 
doctors,  I  left  for  Chicago.  There  my  hand  was  ex- 
amined by  a  number  of  prominent  physicians.  Each 
man  had  a  diagnosis  of  his  own.  Dr.  W.  L.  Baum's 
diagnosis  was  staphylococcus  infection.  His  diagnosis 
was  proved  by  both  culture  and  the  microscope.  This 
was  corroborated  by  Dr.  Kanavel. 

"Was  under  treatment  of  these  physicians,  which 
consisted  of  a  bland,  slightly  antiseptic  ointment, 
two  weeks  before  I  noticed  much  change;  but  within 
three  weeks  from  the  time  they  started  treatment  my 
hand  was  thoroughly  healed,  leaving  a  red  scar,  which 
yet  remains.  The  scar  resembles  that  of  a  severe  burn, 
extending  over  the  entire  back  of  the  hand." 


31KWIU 


3T20      0  3D3JJOQ 


CHAPTER   IV. 

MISCELLANEOUS  ABSCESSES. 

COLLAR-BUTTON  ABSCESS  (SHIRT-STUD  ABSCESS) 
(FROG  FELON). 

AMONG  the  local  infections  of  the  hand  none  is  more 
typical  than  the  collar-button  abscess,  or,  as  the  French 
describe  it,  en  bouton  de  chemise.  This  is  an  abscess 
located  at  the  distal  edge  of  the  palm  under  the  dermal 
and  epidermal  tissues.  Its  peculiar  character  is  due 
to  the  fact  that  at  this  site,  in  workingmen,  the  epithe- 
lium becomes  markedly  hypertrophied,  making  a  dense 
sheet  under  which  the  pus  spreads.  An  infection 
present  under  the  derma  passes  through  this  to  the 
epidermal  tissue,  where  a  second  abscess  forms,  thus 
producing  a  dumb-bell-shaped  accumulation  of  pus. 
The  pus  may  locate  primarily  in  the  epidermic  space 
and  erode  through  the  dermal  tissue  rather  than 
through  the  dense  epidermis  to  the  surface,  producing 
the  same  condition.  It  is  possible  that  this  latter 
course  is  more  common  than  the  former. 

These  abscesses  doubtless  owe  their  origin  to  the 
lessened  resistance  due  to  trauma  more  than  those 
developing  elsewhere,  for  here  the  thickened  area  of 
superficial  cornified  epithelium  is  frequently  opened 
by  cracking,  infection  ensues  in  the  deeper  area  by 
lymphatic  extension,  or,  if  the  cracks  are  deep,  by 
direct  inoculation.  Here  it  finds  excellent  food  for 
development,  since  the  repeated  trauma  has  lowered 
the  normal  resistance  found  in  healthy  tissue. 

In  this  connection  attention  should  be  drawn  to  the 


COLLAR-BUTTON  ABSCESS 


53 


fact  that  at  the  lower  or  distal  end  of  the  palmar 
aponeurosis  the  sheet  may  become  very  thin  in  spots, 
particularly  between  the  processes  which  blend  with 
the  tendon  sheaths  and  the  superficial  transverse  liga- 
ment, and  hence  above  the  canal  for  the  lumbrical 
muscles.  Here,  by  noting  one's  hand,  slight  elevations 
of  tissue  may  be  seen,  cushions  of  fatty  tissue.  When 
pus  accumulates  at  this  point  it  spreads  very  easily 
into  the  web  of  the  finger,  and  in  those  anomalous 

FIG.  17 


Schematic  drawing,  showing  distal  palmar  abscess  and  its  extension  into  the 
dorsal  tissue  between  the  fingers. 

cases  where  the  fascia  is  lacking  to  any  extent  these 
shirt-button  abscesses  would  enter  the  fat  space  and 
spread  down  into  the  cellular  tissue  of  the  web  point- 
ing on  the  dorsum  between  the  bases  of  the  fingers. 
Then  the  dumb-bell  abscess  would  have  from  its  second 
chamber  a  connection  with  a  still  larger  one  on  the 
dorsum,  a  sort  of  chain  of  lakes  of  pus  (Fig.  17). 

In  relation  to  this,  two  very  interesting  cases  can 
be  cited,  showing  how  infection  apparently  in  nearly 
the  same  site  may  occupy  different  spaces. 


54  MISCELLANEOUS  ABSCESSES 

CASE  IV. — From  Northwestern  University  Medical 
School  Dispensary.  History:  C.  B.,  carpenter  by  trade, 
has  been  using  a  chisel  several  days  in  succession 
almost  constantly.  He  hits  the  handle  of  the  chisel 
with  the  palm  of  the  hand  to  force  it  along.  Two  days 
ago  the  patient  began  to  note  tenderness  at  the  distal 
portion  of  the  palm  between  the  base  of  the  index  and 
middle  fingers,  about  2  cm.  from  web.  Upon  examina- 
tion this  was  found  to  be  tender  to  pressure,  and  had 
considerable  local  hardness.  Slight  edema  of  dorsum. 
Temperature,  99°;  pulse,  85. 

Treatment. — Incision  was  made  over  the  area  and  a 
small  amount  of  pus  evacuated.  This  was  under  the 
deeper  layers  of  skin  lying  upon  the  transverse  fascia 
in  the  pad  of  fat  found  in  this  region. 

CASE  V. — E.  A.  Applied  to  dispensary  of  North- 
western University  Medical  School  November  5,  1904. 
The  patient  noticed  pain  and  tenderness  at  base  of  ring 
and  middle  fingers,  about  1.5  cm.  from  web.  Swelling 
and  redness  had  been  increasing  for  four  days.  Tempera- 
ture, 99°;  pulse,  86.  Local  swelling  and  redness  at  site 
noted,  involving  web  also,  but  most  marked  above. 
Tenderness  noted  as  severe. 

Diagnosis. — Abscess,  subdermal,  above  aponeurosis. 
Operation:  ethyl  chloride  spray,  and  incision  made  over 
site  of  greatest  tenderness,  down  through  deep  layers 
of  palmar  skin.  Moderate  amount  of  pus  escaped,  and 
upon  inserting  probe  the  larger  part  of  the  pus  was  found 
to  be  in  the  cellular  tissues  of  the  dorsal  web  area,  ]/2  inch 
back  from  web.  Through-and- through  drainage  inserted. 

November  9,   nearly  well.     Patient  did  not  return. 


Here  we  see  two  abscesses  to  all  appearances  in  the 
same  place,  yet  in  reality  very  different,  being  so  near 
the  distal  edge  of  the  transverse  ligament  that  while 
one  was  confined  to  the  subdermal  tissue,  the  second 
had  invaded  the  adjacent  cellular  tissue  of  the  web, 
and  spread,  by  continuity  of  spaces,  into  the  loose 
tissue  of  the  dorsum,  where  most  of  the  pus  was 
localized. 


A  BSC  ESSES  IN  THEN  A  R  A  ND  H  Y  POT  II  EN  A  R  SPA  CES     55 

TREATMENT. — The  treatment,  therefore,  consists  in 
being  certain  that  the  second  pocket  is  opened  if  it 
be  present,  and  not  being  content  when  after  incising 
free  discharge  of  pus  is  noted.  Always  examine  care- 
fully by  inspection  or  a  probe  for  the  second  pocket. 
If  the  pus  has  extended  to  the  space  in  the  web,  it 
may  be  drained  by  a  through-and-through  incision 
from  the  palmar  to  the  dorsal  surface  through  the  web. 
I  have  at  times  cut  the  web  completely  without  noting 
any  subsequent  impairment  of  function. 


LOCALIZED  ABSCESSES  IN   THE  THENAR  AND   HYPOTHENAR 

SPACES. 

In  the  thenar  region  several  minor  and  indefinite 
spaces  lie  beneath  not  only  the  skin,  but  also  the  fascia 
which  covers  the  muscles.  The  areas  are  small,  how- 
ever, and  are  generally  opened  through  the  adjacent 
skin  before  any  serious  damage  occurs.  It  is  in  these 
areas  more  often  than  the  thenar  space  proper  that 
direct  infection  from  puncture  takes  place,  since  the 
latter  lies  rather  deeply,  and  to  invade  it  the  puncture 
should  enter  between  the  muscular  body  and  the  ad- 
duction crease,  rather  than  upon  the  prominent  part  of 
the  thenar  eminence.  It  is  well  to  bear  this  in  mind 
in  making  a  diagnosis  as  to  whether  the  thenar  space 
is  involved  or  not,  since  a  minor  infection  in  the  super- 
ficial tissues  of  the  thenar  area  either  upon  the  palmar 
or  dorsal  surface  may  be  associated  with  great  edema 
upon  the  dorsum,  and  thus  confuse  the  surgeon  and 
lead  to  a  diagnosis  of  pus  in  the  thenar  space  when  it 
is  uninvolved.  This  error  occurred  in  one  of  my  cases, 
and  is  of  particular  interest,  since  it  demonstrates  that 
treatment  based  upon  this  improper  diagnosis  may 
not  produce  serious  results,  for  here  it  will  be  noted 
that  no  disastrous  sequelae  followed  the  opening  of 


56  MISCELLANEOUS  ABSCESSES 

the  uninfected  space  in  conjunction  with  an  abscess 
of  the  subcutaneous  tissue. 

CASE  VI. — E.  K.  Injured  December  12,  1904,  at  stock- 
yards, by  running  foreign  body  into  thenar  eminence  at 
about  middle  of  palmar  surface.  All  signs  of  localized 
infection  followed,  and  on  December  16  patient  applied 
to  dispensary  for  treatment.  Diagnosis  of  infection  of 
the  thenar  space  made  and  through-and-through  drainage 
of  thenar  areas  instituted,  under  gas  anesthesia.  It  was 
seen  that  the  dorsal  subcutaneous  tissue  only  contained 
pus;  tube  was  withdrawn  and  dorsal  opening  enlarged. 
Patient  made  rapid  recovery  and  was  discharged  in  ten 
days,  apparently  fully  recovered. 

The  hypothenar  area  is  a  closed  space,  as  will  be 
shown  later,  infection  practically  always  arising  from 
direct  implantation  and  localizing  at  that  site.  It 
does  not  spread  out  of  the  space.  Therefore,  there  is 
nothing  peculiar  in  its  pathology  and  the  treatment  of 
its  abscesses  consists  in  simple  incision. 


PART    II. 

GRAVE  INFECTIONS:    TENOSYNOVITIS, 
FASCIAL-SPACE  ABSCESSES,  LYM- 
PHANGITIS, AND  ALLIED 
CONDITIONS. 


CHAPTER  V. 
DIAGNOSIS  IN  GENERAL. 

IT  is  the  purpose  of  this  chapter  to  give  in  general 
the  diagnostic  factors  of  the  three  severe  types  of 
infection,  viz.,  lymphangitis,  tenosynovitis,  and  fascial- 
space  infection.  It  is  not  intended  in  any  sense  as  a 
complete  discussion  of  any,  but  is  introduced  with  the 
idea  that  by  reading  it  the  beginner  may  be  able 
in  any  given  case  to  make  his  diagnosis  in  general, 
and  thus  be  directed  to  the  more  extensive  subsequent 
discussions  for  corroboration.  Therefore,  in  various 
parts  indication  is  made  where  these  can  be  found.  It 
is  desirable  to  emphasize  this,  since  the  greatest  diffi- 
culty to  be  met  in  these  cases  is  the  diagnosis.  Unfor- 
tunately, a  snap  diagnosis  is  too  often  made  and 
incisions  hastily  carried  out  which  jeopardize  the  life 
of  the  patient  and  the  use  of  a  hand,  when  a  little  more 
care  in  the  diagnosis  would  have  led  to  an  immediate 
cure.  It  should  be  emphasized,  further,  that  if  careful 
study  is  made  it  is  possible  in  nearly  every  case  to 
diagnosticate  not  alone  the  nature  of  the  infection,  but 
also  the  location  of  the  pus  if  it  be  present. 


58  DIAGNOSIS  IN  GENERAL 

There  are  certain  facts  which  should  be  remembered : 

1.  The  location  of  the  greatest  swelling  does  not 
indicate  the  position  of  the  pus.    The  excessive  swelling 
comes  in  those  areas  where  there  is  the  largest  amount 
of  loose  cellular  tissue,  i.  e.,  upon  the  dorsum,  while 
in  nine  cases  out  of  ten  the  pus  is  on  the  flexor  surface. 

2.  The  site  of  the  greatest  tenderness  is  of  marked 
importance  in  the  location  of  the  pus. 

3.  The  three  types  of  infection,  viz.,  lymphangitis, 
tenosynovitis,    and     fascial-space     infection,    in    the 
majority   of   cases,  are    distinct   processes,   one    type 
alone  being  present  in  a  given  case.     At  times  the 
types  may  be  combined. 

4.  The  treatment  of  the  three  types  is  essentially 
different,   and  the  gravest  of  errors  will  be  made  if 
they  are  not  differentiated,   since  their  treatment  is 
diametrically  opposed   (see  pp.   259  and  361). 

Let  us  now  take  up  these  three  types  in  order. 

LYMPHANGITIS. 

Lymphangitis  may  be  either  superficial  or  deep. 
Deep  lymphangitis  may  end  in  tenosynovitis  or  ab- 
scess formation  in  the  deep  tissues.  Most  often,  how- 
ever, this  does  not  take  place.  There  is  rapid  increase 
of  swelling  of  the  whole  hand  and  forearm,  with  the 
greatest  redness,  swelling,  and  tenderness  upon  the 
dorsum.  Some  red  lines  of  lymphatic  infection  may 
be  seen  running  up  the  arm,  to  the  axilla  or  elbow. 
There  is  an  absence  of  pain  on  extension  of  fingers 
and  thumb.  The  fingers  can  be  moved  voluntarily 
without  pain,  and  there  is  an  absence  of  tenderness 
over  the  tendon  sheaths  and  the  middle  palmar  and 
thenar  spaces.  There  is  the  absence  of  bulging  of  the 
palm,  although  the  concavity  may  be  lost.  The  patient 
often  presents  great  prostration  (see  pp.  337  and  342). 


TENOSYNOVITIS  59 

The  superficial  type  lacks  the  great  swelling  of  the 
entire  hand  and  forearm.  We  receive  a  history  of  a 
slight  abrasion  or  injury  on  the  hand;  within  a  short 
time  the  patient  complains  of  all  the  symptoms  of 
systemic  absorption — headache,  thirst,  sleeplessness, 
restlessness,  and  fever.  On  examination  we  see 
locally  an  area  of  suffused  redness,  with  a  swelling  of 
the  finger  which  is  involved.  The  color  seldom  becomes 
of  that  violaceous  tint  seen  in  abscess  formation  or  the 
pallor  which  succeeds  it.  In  the  most  acute  types  there 
may  be  little  or  no  edema,  but  most  often  one  finds  a 
considerable  edema  most  marked  upon  the  back  of  the 
hand.  The  swelling  varies  with  the  site  of  the  invasion. 
A  general  rule  may  be  enunciated.  The  lymphatics 
pursue  the  shortest  course  to  the  back  of  the  hand.  In 
other  words,  if  the  infection  enters  at  the  distal  part 
of  the  palm  the  course  will  lie  between  the  bases  of 
the  fingers.  The  lymphatics  upon  the  dorsum  will 
show  up  as  bright  red  streaks  running  up  the  arm. 
Ordinarily  one  or  two  only  will  be  seen  upon  the  back 
of  the  forearm,  although  there  are  fifteen  to  twenty 
here.  The  lymphatics  from  the  little  finger  and  ring 
finger  pass  to  the  glands  in  the  epitrochlear  region, 
and  except  in  the  fulminating  type  these  will  be  found 
enlarged.  From  here  the  infection,  is  carried  to  the 
axillary  region  and  thence  to  the  circulation.  The 
lymphatics  from  the  thumb  and  index  finger  will  be 
found  coursing  upon  the  back  and  outer  side  of  the 
forearm  and  wending  their  way  to  the  axillary  glands 
without  the  intervention  of  the  epitrochlear  glands 
(see  p.  312). 

TENOSYNOVITIS. 

This  type  of  infection  is  much  more  difficult  to 
diagnosticate,  and  the  surgeon  is  often  in  doubt  as 
to  whether  he  is  dealing  with  a  lymphangitis  or 
tenosynovitis. 


60  DIAGNOSIS  IN  GENERAL 

The  disastrous  consequences  of  delayed  diagnosis 
are  so  well  known  that  the  surgeon  should  study  his 
cases  most  carefully,  since  in  nearly  every  case  an 
early  diagnosis  can  be  made  and  the  function  of  the 
hand  saved. 

The   three   cardinal   symptoms   and   signs   are: 

1.  Exquisite  tenderness  over  the  course  of  the  sheath, 
limited  to  the  sheath. 

2.  Flexion  of  the  finger. 

3.  Exquisite    pain    on    extending    the    finger,    most 
marked  at  the  proximal  end. 

These  symptoms  are  seen  to  be  only  a  difference  in 
degree  from  those  found  in  any  infection  of  the  hand, 
but  when  they  are  sought  for  in  an  intelligent  manner 
there  is  not  much  difficulty  in  differentiating  the  con- 
ditions. 

The  size  of  the  primary  wound  is  of  no  importance. 
The  tendon  sheath  may  become  infected  secondarily  to 
a  simple  pin  prick  or  an  extensive  wound.  One  finds 
only  the  cardinal  symptoms  I  have  mentioned,  and  in 
addition  he  may  notice  that  the  abutting  sides  of  the 
adjacent  fingers  are  swollen,  as  well  as  the  back  of  the 
hand.  The  whole  of  the  involved  finger  is  uniformly 
swollen.  The  whole  hand  is  slightly  tender  and  the 
fingers  are  slightly  flexed.  The  involuntary  expression 
of  pain  which  is  noticed  when  the  tendon  sheath  is 
touched  by  the  examining  finger  leaves  no  doubt  in  the 
mind  of  the  examiner  as  to  the  location  of  the  infection. 
The  greatest  amount  of  tenderness  is  generally  com- 
plained of  at  the  proximal  end  of  the  finger  sheath  in 
the  palm  at  the  metacarpophalangeal  articulation.  A 
difference  is  readily  seen  between  the  rigidity  in  the 
infected  finger  and  the  simple  flexion  in  the  adjacent 
digits.  So  great  is  this  difference  that  one  is  able 
to  diagnosticate  an  extension  into  the  palmar  sheath, 
for  instance,  from  the  little  finger  sheath,  since  the 


TENOSYNOVITIS  61 

character  of  the  flexion  changes  to  the  more  rigid 
noted  in  tendon-sheath  infection.  The  spontaneous 
pain,  which  was  at  first  severe,  grows  less  as  the 
edema  develops,  and  may  delude  the  surgeon  into 
believing  that  the  process  is  subsiding.  The  arm 
seems  "to  fall  asleep,"  as  the  patient  expresses  it. 
Paresthesia  with  creeping  and  itching  sensations 
may  be  present,  and,  especially  after  rupture  of  the 
sheath,  the  tenderness  may  subside  to  a  considerable 
degree,  leading  the  surgeon  to  an  early  erroneous 
conclusion. 

An  infection  of  the  sheath  of  the  tendon  in  the  little 
finger  may  be  localized  to  the  finger.  Extensions  to 
other  areas  are  possible,  however.  The  following  are 
the  most  common:  (i)  The  ulnar  bursa;  (2)  the  radial 
bursa;  (3)  the  forearm;  (4)  fascial  spaces  in  the  hand: 
(a)  middle  palmar  space,  (b)  lumbrical  space;  (5) 
osseous  involvement,  middle  phalanx;  (6)  joints, 
proximal  interphalangeal,  wrist;  (7)  rupture  to  the 
surface. 

Extension  to  the  ulnar  bursa  is  often  difficult  to 
diagnosticate.  It  is  marked  by  the  development  of 
edema  in  the  hand,  especially  upon  the  dorsum.  A 
general  fulness  in  the  palm  is  seen,  but  the  palmar 
concavity  is  still  to  be  found.  On  the  flexor  surface 
the  greatest  swelling  is  found  just  proximal  to  the 
annular  ligament.  This  is  not  necessarily  due  to  the 
rupture  of  the  sheath  here,  but  to  the  looseness  of 
the  tissues,  which  permits  of  distention.  This  swell- 
ing is  accentuated  by  the  non-distensible  annular 
ligament  distal  to  it.  The  swelling  in  the  palm  occurs 
at  the  same  time,  but  is  not  so  conspicuous,  owing  to 
the  palmar  fascia.  This  also  diffuses  the  swelling  so 
that  it  is  not  accurately  limited  by  the  outline  of  the 
ulnar  bursa.  Moreover,  the  surrounding  edema  tends 
to  confuse  the  picture  (see  pp.  209  and  212). 


62  DIAGNOSIS  IN  GENERAL 

The  most  conspicuous  and  valuable  sign  is  the  ex- 
tension of  the  exquisite  tenderness  to  the  area  involved. 
It  should  be  remembered  that  this  is  absent  after  a 
few  days.  The  wrist  becomes  fixed,  the  thumb  shows 
tenderness  to  pressure,  and  particularly  on  passive 
movements  is  the  sensitiveness  noted.  It  is  seen  readily 
of  how  much  importance  the  latter  symptom  is  in 
diagnosticating  an  extension  to  the  ulnar  bursa  from 
the  little  finger.  We  note  that  while  at  first  the  symp- 
toms are  limited  to  the  little  finger  and  slight  changes 
in  the  ring  finger,  because  of  its  juxtaposition,  all  at 
once  the  thumb  begins  to  show  the  characteristic  signs 
while  the  index  and  middle  fingers  remain  unchanged 
except  for  the  increase  of  pain  on  passive  extension 
explained  above.  This  sensitiveness  of  the  thumb 
may  be  due  either  to  the  juxtaposition  of  the  sacs,  or 
to  a  real  extension  into  its  sheath.  At  first  there  may 
be  a  diffuse  redness  of  the  palm  and  dorsum,  but  it 
rapidly  gives  place  to  a  whitish  or  even  cyanotic  hue. 
Above  the  wrist,  however,  the  tissue  generally  takes  on 
a  marked  red  color,  which  later  becomes  violaceous. 
The  temperature  and  pulse  may  not  be  of  any  diag- 
nostic importance.  Ordinarily,  after  the  infection  has 
lasted  a  few  days  and  the  walling-off  process  has  begun, 
the  temperature  is  that  of  the  local  accumulations  of 
pus  and  varies  with  the  freedom  of  drainage.  The 
first  few  days,  however,  the  systemic  absorption  bears 
no  relation  to  the  abscess  formation  and  cannot  be 
relied  upon  for  diagnostic  purposes. 

From  the  bursa  various  extensions  may  take  place 
into  the  fascial  spaces  of  the  hand  and  forearm.  The 
symptoms  and  signs  of  this  extension  will  be  taken  up 
under  the  head  of  "Fascial  Space  Infection"  (vide 
infra;  see  also  p.  212). 

Involvement  of  the  index,  middle,  and  ring  fingers 
presents  the  same  signs  as  the  little  finger.  The  only 


FASCIAL-SPACE  INFECTION  63 

difference  is  that  here  the  paths  of  extension  are 
different.  Besides  the  extension  to  the  surface  at  the 
proximal  end,  involvement  of  the  middle  phalanx 
and  the  proximal  interphalangeal  joint,  the  finger 
may  show  extension  to  the  lumbrical  space  on  either 
side,  and  from  here  involve  the  adjacent  tendon 
(see  p.  216). 

Extension  to  the  radial  bursa  is  diagnosticated  as 
following  an  ulnar  bursitis  by  the  increased  swelling 
and  tenderness  in  the  thenar  eminence  and  along  the 
sheath.  The  tumefaction  "of  the  thenar  area  is  not 
that  of  abscess  in  the  thenar  space  (see  p.  224). 

Diagnosis  of  extension  from  a  tenosynovitis  of  the 
thumb  into  the  radial  bursa  and  then  into  the  ulnar 
bursa  is  more  difficult.  We  must  depend  upon  the 
extension  of  the  tenderness  to  the  area  over  the  radial 
bursa  and  the  tenderness  above  the  anterior  annular 
ligament.  When  the  extension  has  proceeded  over 
into  the  ulnar  bursa  the  diagnosis  is  easier,  since  all 
of  the  fingers  become  painful  to  passive  extension, 
most  markedly  the  little  finger,  with  tenderness  over 
the  area  of  the  ulnar  bursa.  The  tenderness  over 
the  sheath  is  not  always  so  marked  in  secondary 
involvement,  however,  due  possibly  to  the  previously 
developed  edema  (see  p.  221). 

The  pus  from  the  radial  bursa  may  rupture  into 
the  tissues  of  the  forearm,  and  then  the  pus  lies  under 
the  flexor  profundus  tendons  just  as  in  rupture  of  the 
ulnar  bursa  (see  p.  155). 


FASCIAL-SPACE  INFECTION. 

Pus  may  be  found  in  various  spaces  in  the  hand  and 
forearm,  as  I  have  already  pointed  out.  This  may  occur 
as  a  primary  infection  or  secondary  to  lymphatic  or 
tendon-sheath  infection,  especially  the  latter.  I  have 


64  DIAGNOSIS  IN  GENERAL 

demonstrated  by  injection  and  serial  sections  the 
spaces  in  which  such  accumulations  can  take  place. 
These  well-defined  spaces  are  five  in  number: 

1.  Middle  palmar  space. 

2.  Thenar  space. 

3.  Hypothenar   space. 

4.  Dorsal  subcutaneous  space. 

5.  Dorsal  subaponeurotic  space. 

The  thenar  and  middle  palmar  spaces  are  by  far 
the  most  important  in  the  hand. 

The  forearm  has  certain  spaces  which  are  likely 
to  become  infected.  Briefly,  it  can  be  stated  that  pus 
which  has  extended  from  the  hand  to  the  forearm 
always  lies  under  the  flexor  profundus,  upon  the 
pronator  quadratus  and  intermuscular  septum.  It 
passes  upward,  following  the  ulnar  artery,  going  as 
high  as  the  elbow  (see  p.  159). 

Now,  how  shall  we  diagnosticate  an  involvement  of 
these  various  spaces?  First,  upon  the  possibility  of 
extension  from  other  foci.  The  middle  palmar  space 
would  receive  infection  by  extension  from  the  middle 
finger,  ring  finger,  little  finger,  also  from  the  ulnar 
bursa  and  localized  infections  in  the  lumbrical  canals 
between  the  heads  of  the  metacarpals.  Again,  it  may 
be  involved  by  direct  implantation  or  through  osteo- 
myelitis of  the  middle  and  ring  metacarpals.  It  is 
possible  for  a  thenar  space  abscess  to  rupture  into  the 
middle  palmar  space  (pp.  168  and  225). 

The  thenar  space  might  receive  the  infection  from 
the  index  finger  or  thumb,  or  by  direct  implanta- 
tion, or  by  osteomyelitis  of  the  index  or  thumb  meta- 
carpals, and  finally  it  would  be  possible  for  the  space 
to  become  involved  secondarily  to  the  middle  palmar 
space  (see  pp.  168  and  225). 

The  forearm  may  be  involved  by  extension  along 
the  connective-tissue  spaces  under  the  tendons  or 


FASCIAL-SPACE  INFECTION  65 

by  rupture  from  either  the  ulnar  or  radial  bursa  (see 
pp.  154  and  394).  The  source  of  the  involvement  of 
the  other  spaces  can  be  readily  surmised  (see  pp.  168 
and  224). 

When  the  middle  palmar  space  is  involved  we  notice 
that  whereas  earlier  there  had  been  a  fulness  in  the 
palm  without  loss  of  the  concavity;  now  the  concavity 
begins  to  be  lost,  and  as  the  process  becomes  marked, 
a  slight  bulging  of  the  palm  is  noticeable  in  spite  of 
the  palmar  fascia.  The  correlation  of  this  with  tender- 
ness is  of  especial  value.  Early,  before  the  swelling 
becomes  marked,  the  tenderness  is  exquisite  and  limited 
by  the  outlines  of  the  middle  palmar  space;  but  as  the 
swelling  increases,  the  tenderness  and  especially  the 
spontaneous  pain  grow  less.  There  is  generally  more 
or  less  extension  along  the  lumbrical  canals,  so  that  the 
swelling  of  the  area  between  the  heads  of  the  meta- 
carpals  adds  to  the  general  picture.  The  area  may  be 
red,  but  generally  it  is  pallid.  With  this  there  is  found 
the  flexion  of  the  fingers  due  to  the  juxtaposition  of 
the  tendons  to  this  area.  They  are  held  rigidly  flexed, 
decreasing  in  rigidity  from  the  little  finger  to  the  index 
finger.  The  latter  may  have  considerable  voluntary 
motion.  If  the  pus  has  extended  along  the  lumbrical 
canals  to  the  base  of  the  fingers,  there  may  be  swelling 
and  induration  in  the  loose  tissue  of  the  web,  and  an 
accumulation  of  pus  may  be  found  to  have  extended  to 
the  dorsum  between  the  bases  of  the  proximal  pha- 
langes. The  relation  of  the  swelling  in  the  palm  to  that 
in  the  thenar  area  is  of  great  importance.  In  involve- 
ment of  the  middle  palmar  space  there  is  an  associated 
swelling  of  the  thenar  space  of  almost  the  same  degree 
as  that  of  the  middle  palmar  space,  but  this  is  due  to 
edema  (see  pp.  225  and  233).  When  the  thenar  space 
becomes  involved  the  swelling  is  out  of  all  proportion 
to  that  of  the  palm  if  it  be  involved.  There  is  the 

5 


66  DIAGNOSIS  IN  GENERAL 

induration  of  infection  rather  than  the  softness  of 
edema.  The  thenar  space  will  look  as  if  a  balloon 
had  been  inserted  into  the  area  and  blown  up  to  its 
full  capacity.  I  know  of  no  clinical  picture  in  surgery 
that  is  more  characteristic  than  this  of  thenar-space 
infection,  and  having  once  seen  it  one  cannot  forget 
it.  Besides  the  ballooning  out  of  the  thenar  area,  the 
metacarpal  of  the  thumb  is  pushed  away  from  the 
hand;  the  flexion  of  the  distal  phalanx  becomes  more 
marked,  though  lacking  the  rigidity  found  in  involve- 
ment of  the  tendon  sheath  of  the  flexor  longus  pollicis. 
This  infection  of  the  thenar  space  may  be  primary  and 
isolated  or  secondary  to  a  middle  palmar  infection  (see 
pp.  1 68  and  224). 

The  edema  upon  the  back  of  the  hand  is  always 
present  and  the  swelling  much  greater,  of  course,  than 
in  the  palm,  even  though  that  be  the  site  of  the  pus. 
It  is  extremely  uncommon  to  find  any  pus  upon  the 
dorsum  unless  there  has  been  a  lymphatic  infection 
or  the  pus  has  extended,  as  already  described,  between 
the  metacarpals  of  the  index  finger  and  thumb  from 
the  thenar  space,  or  between  the  heads  of  the  proximal 
phalanges.  We  should  bear  in  mind  that  edema  gives 
rise  to  a  soft  pitting,  while  if  pus  be  present  induration 
can  always  be  felt.  If  this  fact  is  borne  in  mind  many 
embarrassing  mistakes  will  be  avoided.  I  think  that  in 
three-fourths  of  the  hands  I  see  in  which  treatment  has 
been  instituted  a  number  of  unnecessary  and  improper 
incisions  are  found  upon  the  dorsum  (Fig.  84). 

The  infection  may  spread  from  either  space  to  the 
forearm,  or  this  may  be  involved  from  a  tenosynovitis 
of  the  ulnar  or  radial  bursa.  As  has  been  pointed  out, 
the  pus  in  these  cases  passes  between  the  pronator 
quadratus  and  the  flexor  profundus  to  the  area  between 
the  latter  and  the  interosseous  membrane,  and  at  about 
the  middle  of  the  area  it  passes  more  superficially  and 


FASCIAL-SPACE  INFECTION  67 

to  the  ulnar  side  along  the  ulnar  artery  and  nerve. 
This  extension  is  characterized  by  a  brawny  induration 
that  should  not  be  confused  with  the  softness  of  an 
edema.  No  fluctuation  should  be  expected,  since  the 
accumulation  lies  too  deeply.  If  the  primary  source 
is  the  ulnar  or  radial  bursa,  this  extension  is  marked 
by  the  loss  of  the  relative  swelling  immediately  above 
the  annular  ligament,  due  to  the  distended  upper  end 
of  the  sheath.  This  swelling  is  not  any  less,  but  that 
of  the  arm  is  greater.  The  tenderness  may  become  less, 
so  it  cannot  be  depended  upon  as  a  symptom.  The 
redness  is  generally  greater,  and  spontaneous  pain, 
while  at  first  marked,  rapidly  subsides.  At  this  time 
some  pus  may  accumulate  subcutaneously  above  the 
wrist  and  lead  to  the  supposition  that  there  is  no  pus 
under  the  tendons.  Thus  valuable  time  is  lost  (see 
pp.  216  and  394). 

Involvement  of  the  hypothenar  space  can  often  be 
prognosticated  from  the  site  of  the  primary  injury, 
while  the  relative  lack  of  swelling  in  the  palm  and 
fingers,  with  absence  of  involvement  of  the  tendons, 
combined  with  the  ordinary  symptoms  of  abscess, 
leads  us  to  an  easy  diagnosis.  Fortunately,  the  hypo- 
thenar area  is  so  separated  from  the  remainder  of  the 
hand  that  it  is  not  frequently  involved  secondarily 
to  palmar  infection  (see  pp.  147  and  183). 

An  infection  localized  under  the  subaponeurotic 
fascia  to  the  exclusion  of  the  subcutaneous  tissue  may 
be  difficult  of  differential  diagnosis.  However,  we 
are  aided  materially  if  we  remember  the  character 
of  the  primary  injury,  the  methods  of  extension  to 
this  space  already  mentioned,  and  the  local  evidences 
of  infection  upon  the  dorsum,  with  the  pitting  edema 
of  the  subcutaneous  tissue,  yet  lacking  the  brawny 
induration  and  localized  tenderness  of  a  subcutaneous 
abscess  (see  pp.  147  and  183). 


68  DIAGNOSIS  IN  GENERAL 

We  may  be  in  doubt  as  to  whether  we  are  dealing 
with  a  tenosynovitis  of  the  ulnar  or  radial  bursa  or  a 
rheumatism  of  the  wrist.  I  have  seen  several  such 
cases,  and  in  one  case  it  was  difficult  to  determine 
whether  the  patient  was  suffering  from  a  gonorrheal 
rheumatism  of  the  proximal  interphalangeal  joint  of 
a  finger  or  a  gonorrheal  tenosynovitis  with  secondary 
involvement  of  the  joint.  The  latter  assumption  was 
later  found  to  be  the  condition  present.  In  those  cases 
presenting  an  apparently  spontaneous  development  of 
an  inflammation  at  the  wrist,  the  diagnosis  may  be  most 
difficult  in  spite  of  the  ease  with  which  a  theoretical 
differential  diagnosis  is  made.  Here  again,  however, 
the  localized  tenderness  over  the  sheath  and  pain  on 
extension  of  the  finger  are  of  the  greatest  importance. 
Moreover,  these  cases  are  always  virulent  and  extend 
rapidly,  so  that  if  it  be  a  tenosynovitis  the  hand  grows 
rapidly  worse.  In  a  rheumatism  there  is  as  much 
pain  on  the  dorsal  as  on  the  volar  surface,  the  swelling 
involves  the  wrist  more  than  the  hand,  fingers,  or 
forearm,  and  other  joints  may  be  involved.  The 
presence  of  a  gonorrhea  does  not  aid  us  materially 
since  either  condition  may  follow. 


DIAGNOSIS  OF  EXTENSIONS  FROM  VARIOUS  SITES. 

The  diagnosis  of  the  extensions  from  various  sites 
is  of  the  greatest  importance  from  a  therapeutic  stand- 
point. I  have  worked  out  these  possibilities  by  both 
experimental  and  clinical  observations.  The  present 
chapter  is  too  brief  to  allow  a  full  discussion.  I  shall, 
however,  append  a  tabulation,  with  references  attached, 
denoting  where  a  complete  discussion  of  each  subject 
can  be  found. 

If  the  infection  originates  in  the  thumb,  for  possible 
extensions  see  p.  194. 


DIAGNOSIS  OF  EXTENSIONS  FROM  VARIOUS  SITES    69 

If  the  infection  originates  in  the  index  finger,  for 
possible  extensions  see  p.  185. 

If  the  infection  originates  in  the  middle  finger,  for 
possible  extensions  see  p.  195. 

If  the  infection  originates  in  the  ring  finger,  for 
possible  extensions  see  p.  197. 

If  the  infection  originates  in  the  little  ringer,  for 
possible  extensions  see  p.  198. 

If  the  palmar  space  is  involved,  for  possible  exten- 
sions see  pp.  144  and  176. 

If  the  thenar  space  is  involved,  for  possible  exten- 
sions see  pp.  145  and  181. 

If  the  forearm  is  involved,  for  possible  extensions 
see  pp.  159  and  396. 

If  the  ulnar  bursa  is  involved,  for  possible  exten- 
sions see  pp.  121  and  212. 

If  the  radial  bursa  is  involved,  for  possible  extensions 
see  pp.  126  and  221. 


CHAPTER  VI. 
GENERAL  PRINCIPLES  OF  TREATMENT. 

IT  is  not  the  intention  here  to  discuss  in  detail  the 
treatment  of  the  various  types  of  infections.  Specific 
directions  for  dealing  with  individual  cases  will  be 
discussed  in  the  chapters  devoted  to  the  different 
types.  It  is  proper,  however,  to  deal  with  the  general 
principles  underlying  the  various  procedures  which 
might  be  scattered  in  the  succeeding  chapters. 

The  early  treatment  in  any  case  has  for  its  pur- 
pose the  walling  off  of  the  infection,  or  its  removal 
by  phagocytic  action. 

PROPHYLAXIS. — Great  care  should  be  used  in  the 
preliminary  treatment  of  minor  as  well  as  major 
injuries,  especially  in  factories.  If  the  foremen  were 
taught  to  insist  upon  each  man  taking  proper  pre- 
cautions, many  hands  would  be  saved.  Every  man 
injured  should  apply  at  once  to  the  foreman,  who 
should  pour  iodine  into  the  wound  and  apply  a  light 
sterile  bandage  for  24  hours.  There  should  be  no 
preliminary  scrubbing  or  washing.  This  system  could 
be  instituted  in  all  factories  with  little  difficulty. 

REST. — Rest  is  one  of  the  essential  factors,  at  least 
in  a  negative  sense.  The  extremity  affected  should 
always  be  so  fixed  that  movement,  either  of  the  whole 
or  muscular  action  of  a  part,  is  impossible,  since  it 
is  well  known  that  the  lymphatic  streams  are  aided 
materially  in  their  return  flow  by  muscular  action. 
It  will  undoubtedly  relieve  the  patient  somewhat  of 
the  throbbing  pain  to  have  the  hand  elevated  after 
the  von  Volkmann  method,  but  beyond  that  I  cannot 
feel  that  the  procedure  is  of  great  therapeutic  value. 


PASSIVE  HYPEREMIA  71 

Positive  factors  designed  to  increase  phagocytic 
action  are  still  subject  to  discussion,  in  spite  of  the 
extensive  contributions  in  support  of  this  or  that  pro- 
cedure. They  may  be  classified  as  systemic  and  local. 
The  local  again  are  divided  into  the  results  of  active 
hyperemia  and  of  passive  hyperemia. 

DRUGS.  —  The  systemic  use  of  drugs,  such  as  nucleic 
acid,  etc.,  to  increase  leukocytosis,  has  never  been 
followed  by  such  marked  and  positive  results  as  to 
prove  beyond  question  the  advisability  of  their  use, 
and  all,  so  far  as  known,  may  ultimately  be  dis- 
carded, as  was  turpentine,  which  preceded  them. 
They  have  never  given  any  results  in  my  hands.  We 
are  not  now  discussing  the  applicability  of  drugs 
and  sera  in  systemic  infections.  They  will  be 
taken  up  under  that  heading  later  (see  pp.  366  and 


PASSIVE  HYPEREMIA.  —  Among  the  local  procedures 
those  producing  passive  hyperemia  (Bier)  have  re- 
ceived the  greatest  attention  in  later  years.  While 
much  of  an  enthusiastic  nature  has  been  written  in 
favor  of  this  method,  it  is  probable  that  the  American 
surgeons  have  not  secured  the  results  claimed  for  it 
by  its  German  supporters.  It  is  not  the  province  of 
such  a  contribution  as  this  to  review  the  subject,  with 
a  discussion  of  the  various  theories  as  to  the  changes 
in  the  blood;  the  lessened  resistance  as  claimed  by 
some  and  the  raised  opsonic  index  as  maintained  by 
others.  My  personal  opinion  has  become  quite  settled 
as  to  its  value  in  acute  infections.  I  have  found  its 
chief  value  in  three  conditions: 

i.  In  those  conditions  in  which  I  wish  to  prevent 
the  rapid  absorption  of  toxins  into  the  circulating 
blood,  as,  for  instance,  in  an  acute  lymphangitis  (see 
pp.  363  and  364),  or  immediately  after  incising  viru- 
lent abscesses  of  the  hand  and  arm  where  a  marked 


72  GENERAL  PRINCIPLES  OF  TREATMENT 

constriction  will  reverse  the  lymph  stream  and  tend 
to  wash  the  toxins  out  into  the  wound,  preventing 
absorption  (see  pp.  235  and  287). 

2.  In  those  cases  in  which  the  process  has  become 
semichronic  with  a  low  grade  of  infection  (see  pp.  236 
and  446). 

3.  In  the  case  of  localized  abscesses  which  do  not 
drain  freely.     Here  the  suction  cup  is  of  especial  value 
(see  p.  446). 

Beyond  these  conditions  I  must  say  I  look  upon  it  as 
a  possible  adjuvant  in  the  treatment,  but  never  as  the 
primary  factor.  It  follows,  therefore,  that  early  in  the 
course  of  an  infection,  if  we  suspect  the  process  to  be 
particularly  virulent,  a  bandage  may  be  applied  to  the 
arm  after  the  method  described  on  pp.  235  and  363. 
Any  other  method  is  painful  and  may  even  be  harmful. 
In  the  ordinary  cases  I  have  contented  myself  with 
other  means,  namely,  hot,  moist  dressings,  the  use  of 
which  it  would  appear  rests  upon  a  more  rational  basis. 
Klapp  has  emphasized  the  value  of  suction  cups  used 
over  a  localized  infection.  He  has  devised  various 
types  to  fit  various  areas.  Their  value  in  certain 
conditions  cannot  be  gainsaid,  particularly  in  those 
cases  which  would  be  classified  in  the  second  and 
third  groups  above. 

HOT  MOIST  DRESSINGS. — These  are  in  common  use 
by  all,  and  have  proved  beneficial  in  many  cases.  The 
most  common  form  in  which  they  are  applied  is  that 
of  the  saturated  hot  boric  acid  solution,  although  many 
other  medicaments  are  employed,  such  as  potassium 
permanganate,  alcohol,  bichloride,  etc.  The  solution 
of  hot  boric  acid,  in  my  opinion,  depends  for  its  effi- 
ciency largely  upon  the  moist  heat,  although  scientific 
evidence  is  not  wanting  that  its  chemical  action  may 
be  of  some  value.  In  this  connection  Dr.  E.  H. 
Ochsner  reports  that  Professor  Kakenberg,  at  the 


HOT  MOIST  DRESSINGS  73 

University  of  Wisconsin,  conducted  a  series  of  examina- 
tions demonstrating  the  presence  of  a  small  amount 
of  boric  acid — o.oi  to  0.03  per  cent. — in  urine  voided 
after  hot  applications  of  a  saturated  solution  of  boric 
acid  in  water,  3  parts,  and  95  per  cent,  alcohol,  I  part. 
This  is  not  the  occasion  to  discuss  the  question  as  to 
the  bactericidal  effect  of  boric  acid,  especially  in  small 
percentages.  Other  investigators  have  maintained 
that  a  large  percentage  is  found  in  the  skin  and  sub- 
cutaneous tissue.  The  dressings  may  be  applied  as 
follows:  The  saturated  solution  is  boiled  and  then  set 
aside,  and,  as  it  is  desired,  it  is  heated  to  as  great 
a  heat  as  can  be  borne  by  the  bare  forearm  of  the 
attendant.  Greater  heat,  as  demanded  by  some,  is  not 
needful.  The  patient  should  not  be  left  to  decide 
"if  he  can  stand  it,"  since  the  infected  hand  is  often 
very  insensitive  to  superficial  pain,  and  the  inadvertent 
application  of  the  excessive  heat  may  lead  to  blisters 
which  will  be  annoying  and  prolong  convalescence. 
After  the  desired  temperature  is  secured  a  sterile 
towel  is  unfolded,  the  dressings  are  dropped  into  it, 
and  it  is  then  immersed  at  its  middle  in  the  water. 
The  dressings  are  wrung  dry  by  turning  the  two  dry 
ends  in  opposite  directions,  thus  securing  the  dressings 
properly  saturated  and  wrung  out,  but  still  sterile. 
The  dressing  is  now  applied  widely,  covering  the 
entire  infected  area,  going  proximally  some  inches. 
Fear  rather  that  your  dressing  may  be  too  small  than 
too  voluminous.  The  whole  is  covered  by  some 
impervious  material,  such  as  paper  saturated  with 
paraffin  or  sheet  gutta-percha.  This  should  be 
covered  by  a  layer  of  cotton  followed  by  a  bandage. 
Provision  should  be  made  at  the  time  of  dressing  for 
subsequent  applications  of  the  solution  by  making 
a  hole  or  two  through  the  outside  covering  down  to 
the  dressing.  Through  these  openings  the  boric  acid 


74  GENERAL  PRINCIPLES  OF  TREATMENT 

solution  should  be  poured  every  two  hours,  and  the 
hand  dressed  as  frequently  as  necessary. 

Too  often  we  see  the  hot  boric  acid  continued  for 
several  days.  It  is  not  only  useless  but  harmful  to 
continue  this  treatment  after  the  process  is  once  under 
control,  since  it  tends  to  favor  congestion  and  round- 
celled  exudation,  which  if  long  continued  produces  a 
soggy,  infiltrated  hand,  in  which  absorption  is  slow,  and 
as  a  consequence  the  ravages  of  the  disease  are  slowly 
repaired  and  fibrinous  ankylosis  of  joints,  adhesions 
of  the  tendons,  shrinking  of  muscles,  and  fibrosis  in 
all  the  various  structures  are  favored. 

As  soon  as  the  process  has  subsided  it  may  be  treated 
in  various  ways,  according  to  the  condition.  In  the 
presence  of  congestion,  a  dressing  saturated  with  a 
weak  solution  of  alcohol  or  equal  parts  of  alcohol  and 
glycerin  will  aid  in  the  dehydration.  If  there  is  a 
foul  discharge,  a  i  to  2000  potassium  permanganate 
dressing  is  advisable.  If  there  are  many  raw  surfaces 
requiring  dressing,  the  gauze  may  be  saturated  with 
vaseline,  which  permits  of  painless  dressing  and  does 
not  retard  drainage.  Against  alcohol  may  be  urged 
with  justice  its  inflammability,  so  that  it  should 
always  be  used  with  care.  One  case  came  to  my  notice 
in  which  the  patient  was  severely  burned  through 
its  use. 

PROPHYLACTIC  INCISION. — One  constantly  meets  cases 
in  which  the  patient  has  been  subjected  to  incision 
at  some  swollen  or  tender  area,  under  the  assump- 
tion that  if  there  is  not  pus  there  the  "drainage  will 
do  good  anyway."  Such  incisions  are  always  ill- 
advised,  since  they  nearly  always  do  more  harm  than 
good.  A  general  rule  should  be  laid  down  not  to  incise 
unless  the  surgeon  has  an  accurate  appreciation  of  the 
condition  and  an  absolute  diagnosis  made.  In  general 
one  may  say  that  incision  in  lymphatic  infections 


PROPHYLACTIC  INCISION  75 

should  be  made  as  a  last  resort  or  because  of  secondary 
complications  (see  pp.  364  and  372).  Tenosynovitis 
should  be  treated  by  drainage  as  soon  as  the  diagnosis 
is  made  (see  pp.  257  and  259).  Abscesses  of  the  fascial 
spaces  are  never  so  urgent  as  to  demand  operation 
before  one  is  sure  of  the  diagnosis.  These  rules  are 
urged  most  emphatically,  since  I  see  in  consultation 
fully  as  many  cases  in  which  the  incision  made  has 
been  ill-advised  or  unnecessary  as  I  do  those  in  which 
further  surgical  work  is  indicated. 

When  incision  has  been  decided  upon  certain  rules 
are  imperative  in  the  severe  case.  The  operation  should 
be  done  in  a  bloodless  field.  A  Martin  bandage  is  to 
be  preferred  which  is  applied  from  the  elbow  to  the 
shoulder.  After  the  operation  is  concluded  the  band- 
age is  loosened  slightly,  just  enough  to  allow  circulation, 
but  still  tight  enough  to  prevent  rapid  absorption. 
In  fact,  I  attempt  to  produce  a  Bier's  hyperemia. 
This  is  done  with  the  hope  of  preventing  the  rapid 
absorption  of  toxins.  In  a  patient  who  is  severely 
ill  such  rapid  absorption  may  take  place  as  to  over- 
whelm the  system  before  it  has  an  opportunity  to 
develop  antitoxins,  while  if  the  bandage  is  removed 
through  the  course  of  twenty-four  hours  the  system 
may  have  an  opportunity  to  develop  antitoxins  and 
ward  off  a  systemic  infection  that  might  ultimately 
lead  to  death.  Again,  the  patient  should  always  be 
anesthetized.  Nitrous  oxide  is  the  anesthetic  of  choice, 
owing  to  its  non-toxic  action.  This  gives  time  for 
carefully  placed  and  adequate  incisions.  The  surgeon 
should  always  convince  himself  before  allowing  the 
patient  to  awaken  that  he  has  done  the  work  thor- 
oughly so  that  the  operation  will  not  have  to  be  re- 
peated upon  subsequent  days.  This  cannot  be  done 
under  local  anesthesia.  Moreover,  the  hypodermic 
injection  of  tissue  about  an  infected  area  cannot  be 


70  GENERAL  PRINCIPLES  OF  TREATMENT 

done  without  danger  of  causing  a. spread  either  locally 
or  systematically. 

DRAINAGE. — Drainage  of  wounds .  by  means  of 
gauze,  tubes,  etc.,  is  not  of  the  importance  attributed 
to  it  by  some.  The  essential  factor  is  to  make  the 
incision  at  the  right  place  and  of  adequate  size.  If  this 
is  done,  drainage  strips  will  be  not  only  unnecessary 
after  the  first  forty-eight  hours,  but  often  positively 
detrimental  to  recovery.  After  incision  it  is  my  custom 
to  use  either  plain  gauze,  gauze  saturated  with  vase- 
line, or  gutta-percha  strips.  The  former  is  used  only 
when  there  is  venous  oozing  and  we  desire  to  stop  it 
by  favoring  coagulation.  We  must  never  expect  it  to 
do  more  than  this,  and  keep  the  edges  of  the  wound 
separated,  for  the  plain  gauze  mesh  is  soon  filled  with 
pus  and  coagulated  serum,  which  acts  as  an  effectual 
bar  to  drainage.  Where  there  is  no  bleeding,  gauze 
strips  thoroughly  saturated  with  vaseline  or  gutta- 
percha  strips  are  used.  These  secure  adequate  drain- 
age, and  can  be  removed  without  pain.  They  are  left 
in  for  twenty-four  to  forty-eight  hours;  if  left  in  longer 
they  prolong  the  suppuration.  It  has  happened  to 
every  surgeon  to  see  cases  in  which  the  wound  has 
been  kept  open  for  weeks  by  ill-advised  drainage 
material.  Rubber  tubes  are  never  used,  since  they 
favor  tissue  necrosis  and  are  not  any  more  satisfactory 
for  drainage  than  gutta-percha  strips. 

It  has  been  suggested  by  some  that  in  order  to 
prevent  rapid  absorption  and  danger  of  generalized 
infection,  it  would  be  advisable  to  open  abscesses  by 
the  cautery,  and  again  others  have  suggested  painting 
the  cut  edges  with  some  solution  of  iodine.  The 
advisability  of  this  procedure  is  open  to  discussion, 
since  it  surely  should  not  be  used  unless  the  abscess 
is  thoroughly  walled  off,  in  which  case  it  is  possible 
to  conceive  of  this  procedure  being  pathologically 


STIMULATION  OF  EXCRETION  77 

sound.  In  a  majority  of  cases,  however,  bacteria  and 
toxins  in  the  wall  are  thus  sealed  up  and  serum  drain- 
age by  the  method  I  have  suggested  is  prevented 
(see  pp.  236  and  284).  Thus  the  patient  is  in  greater 
danger  of  systemic  infection  or  prolonged  local  dis- 
turbance. It  is  my  personal  belief  that  any  procedure 
which  impairs  the  vitality  of  tissue  cell  life,  thus 
reducing  its  resistance  and  reparative  powers,  will 
be  discarded  in  the  end. 

The  common  habit  of  pressing  and  squeezing  wounds 
with  the  purpose  of  forcing  out  the  contained  pus 
cannot  be  too  severely  condemned.  It  is  both  un- 
necessary and  harmful.  If  adequate  incision  is  made, 
the  pus  free  in  the  abscess  will  drain  out,  and  if  it  is 
in  the  layers  of  fascia  adjacent  to  the  wound,  pressure 
is  just  as  likely  to  force  it  farther  into  the  tissue  as 
into  the  abscess  cavity.  If  the  opening  is  small  and 
drainage  inadequate  because  of  the  thickness  of  the 
pus  the  wound  should  be  opened  more  widely,  or  the 
pus  removed  by  the  Klapp  suction  cup.  If  the  open- 
ing is  plugged  by  seminecrotic  connective  tissue,  it 
may  be  removed  by  the  forceps,  never  with  a  sharp 
curette.  To  repeat,  the  pressure  and  squeezing  tend 
to  disseminate  the  infection  throughout  the  surround- 
ing tissue  and  even  produce  systemic  infection  or 
dislodge  septic  thrombi. 

After  almost  all  incisions  in  virulent  cases  there  is 
severe  local  reaction,  causing  more  swelling  in  the  first 
twenty-four  to  thirty-six  hours.  At  the  end  of  that 
time,  if  the  process  has  been  properly  drained,  the 
swelling,  and  temperature  should  begin  to  subside. 

STIMULATION  OF  EXCRETION. — The  excretions  should 
be  stimulated,  particularly  by  the  introduction  of 
large  amounts  of  water  into  the  system.  This  may  be 
done  subcutaneously  by  rectum  or  by  mouth,  accord- 
ing to  the  conditions  to  be  met.  If  introduced  by 


78  GENERAL  PRINCIPLES  OF  TREATMENT 

rectum,  ordinary  tap  water  has  been  more  satis- 
factory than  normal  salt  solution,  since  it  is  better 
borne  by  the  patient  and  relieves  his  thirst  more 
quickly.  In  the  severe  toxemias  I  also  use  alcohol 
and  peptonized  foods  for  the  reasons  enumerated  later 
(see  p.  366). 

MASSAGE. — The  early  use  of  massage  and  passive 
motion  is  one  of  the .  essentials  in  the  production  of 
functionating  hands.  Its  use  is  particularly  urged  in 
tendon-sheath  infection  (see  p.  286). 

BAKING  IN  DRY,  HOT  AIR. — Auchincloss,  who  has 
made  an  extensive  study  of  infections  of  the  hand, 
tells  me  that  he  has  had  most  satisfactory  results  from 
the  use  of  baking  in  dry,  hot  air.  He  is  convinced 
that  this  gives  the  patient  much  comfort  and  adds  to 
the  recovery  after  hot  fomentations  in  the  acute  as 
well  as  the  chronic  cases.  The  idea  seems  to  be  per- 
fectly rational  and  I  believe  will  be  a  distinct  addition 
to  our  therapy  in  these  cases. 


SECTION    I. 

THE  ANATOMY  OF  THE  HAND  AND  FOREARM, 

WITH  ESPECIAL  CONSIDERATION  OF  ITS 

RELATION  TO  INFECTIONS  OF  THE 

SYNOVIAL   SHEATHS    AND 

FASCIAL  SPACES. 


CHAPTER  VII. 

METHODS  OF  STUDY  IN  GENERAL:  STUDY  OF  SERIAL 

CROSS-SECTIONS  OF  THE  HAND,  WITH  PARTICULAR 

RELATION  TO  THE  FASCIAL  SPACES. 

UPON  beginning  the  study  of  infections  of  the  hand 
it  was  realized  immediately  that  our  general  knowledge 
of  the  anatomy  was  entirely  inadequate  when  we  came 
to  apply  it  to  specific  conditions.  The  first  problem, 
therefore,  with  which  we  had  to  deal  was  a  thorough 
study  of  the  anatomy  carried  out  entirely  in  relation 
to  this  question.  As  the  work  progressed,  its  immense 
value  from  a  diagnostic  and  therapeutic  standpoint 
began  to  be  realized.  The  reasons  for  many  failures 
in  treatment  were  seen.  The  diagnosis  was  placed 
upon  a  firm  basis.  We  are  firmly  convinced  that  any- 
one who  wishes  to  master  the  proper  steps  in  diagnosis 
and  treatment  must  follow  step  by  step  the  unfolding 
of  the  anatomical  picture  as  we  shall  try  to  present 
it  in  the  subsequent  pages.  It  will  be  discussed  in 
the  following  manner: 


80  METHODS  OF  STUDY  IN  GENERAL 

Anatomy  of  the  Hand  and   Forearm,   with  Surgical 
Deductions. 

A.  Anatomy  of  the  hand. 

I.  Methods  of  study. 

II.  Study  of  serial  cross-sections,  with  particu- 
lar relation   to  fascial  spaces. 

III.  Study   of   the   tendon   sheaths   in   general. 

IV.  Study    of    the    fascial    spaces    and    tendon 

sheaths  by  means  of  experimental  injections. 
V.  Study  of  x-ray  pictures  of  injected  hands. 
VI.  Study  of  the  embryology. 

B.  Anatomy  of  forearm. 

I.  Anatomy  in  general. 
II.  Study  of  serial  cross-sections. 
III.  Study    by    means    of    injection    of    the    con- 
nective-tissue   spaces. 

METHODS  OF  STUDY. 

I.  With  the  object  of  securing  a  tentative  picture 
of  the  spaces  and  their  relation  to  the  tendon  sheaths 
in  particular  and  other  structures  in  general,  a  freshly 
amputated  cadaver  hand  was  hardened  in  formalin 
and  cross-sections  made,  beginning  at  the  middle 
joints  of  the  fingers,  and  cutting  sections  about  one 
centimeter  in  width,  going  as  high  as  the  elbow.  The 
fascial  layers  were  then  teased  out  and  their  relations 
to  the  muscles,  bones,  tendons,  nerves,  and  blood- 
vessels determined.  The  prolongations  of  the  various 
spaces  were  followed  up,  each  space  and  each  tendon 
sheath  being  followed  from  one  section  to  another; 
thus,  their  limitations  were  determined  and  the  rela- 
tion of  the  various  adjacent  structures  noted.  The 
specimen  chosen  was  one  with  but  little  fat  (Fig.  18). 

The  same  process  was  carried  out  in  a  fresh  cadaver 


METHODS  OF  STUDY 


81 


hand  in  which  the  vessels  were  injected  and  the  sections 
cut  while  the  hand  was  frozen.  Sections  were  made  of 
a  third  hand  at  right  angles  to  the  metacarpal  bone  of 
the  thumb,  since  it  was  found  that  the  findings  in  the 
thenar  area  were  somewhat  confusing.  This  hand  also 
was  frozen,  and,  like  the  first  and  second,  without 
much  fat.  By  these  sections  a  fairly  definite  idea  of 
the  spaces  was  secured. 


FIG.  1 8 


' 


Drawing  made  from  specimen  showing  sites  of  the  various  sections  taken 
through  the  hand. 

2.  To  corroborate  the  findings  above,  as  well  as  to 
determine  their  exact  limitations,  injections  wrere  made 
into  the  various  fascial  spaces,  by  various  channels, 
and  with  varying  degrees  of  force.  This  determined 
not  alone  the  positions  and  relations  of  the  pockets, 
but  also  by  what  channel  pus  could  reach  them  and 
where  it  would  extend  if  it  broke  through  the  walls 


82  METHODS  OF  STUDY  IN  GENERAL 

of  the  closed  fascial  spaces.  By  this  we  also  deter- 
mined the  course  pus  would  pursue  when  it  ruptured 
from  the  tendon  sheaths,  and  thus  fixed  the  relation  of 
the  tendon-sheath  infections  to  fascial-space  infections. 
The  findings  were  very  uniform  and  satisfactory,  with 
the  exception  of  three  or  four  which  did  not  reach  the 
spaces  intended.  The  material  used  was  such  as  is 
ordinarily  found  in  the  dissecting  room;  hence,  while 
the  part  was  always  well  preserved,  in  some  cases  the 
material  was  more  friable  than  in  others,  and,  therefore, 
rupture  from  the  space  was  more  likely  to  occur.  How- 
ever, this  does  not  interfere  with  the  deductions,  since 
the  changes  present  were,  in  a  measure,  comparable 
to  those  found  in  inflammatory  processes.  Moreover, 
no  matter  whether  the  tissue  was  fresh  or  preserved, 
the  findings  were  the  same,  so  we  may  feel  sure  that  the 
results  are  to  be  depended  upon. 

The  fascial  spaces  of  56  hands  and  forearms  were 
injected  from  various  sites  by  plaster  of  Paris,  which 
had  been  rubbed  up  with  glycerin  and  diluted  with 
water.  It  was  injected  by  means  of  a  hand  pump 
through  a  cannula,  which  was  inserted  at  various 
points,  as  will  be  noted  later.  As  the  hands  were 
dissected,  the  location  and  paths  of  extension  of  the 
masses  were  noted.  In  those  cases  injected  with 
moderate  force  a  pressure  of  4  to  8  pounds  was 
used,  and  where  forcible  injection  is  noted,  25  to  35 
pounds. 

3.  Several  hands  were  injected  as  above,  except  that 
the  injection  mass  was  impregnated  with  red  lead. 
X-ray  pictures  were  taken.  This  showed  the  relation 
of  the  theoretical  pus  accumulations  to  the  bones  and 
bloodvessels,  the  latter  having  been  injected  with  the 
same  mass.  Again,  in  other  hands,  injections  of  vari- 
ous spaces  were  made,  concomitant  with  injections  of 
the  synovial  sheaths,  to  show  their  relation  and  the 


A  STUDY  OF  SERIAL  CROSS-SECTIONS  83 

proper  site  for  operations  designed  to  open  the  former 
without  injury  to  the  latter. 

4.  After  this  work  had  been  done  a  study  of  the 
embryology  was  made,   with   a  view  of  determining 
whether  or  not  there  was  any  relation  between  the 
anatomical  peculiarities  of  the  spaces  and  the  embryo- 
logical  development. 

5.  The  clinical  cases  which  came  under  observation 
were  observed  very  carefully  to  see  if  the  real  pathology 
corresponded  with  the  anatomical  demonstration.  Bac- 
teriological studies  of  all  cases  were  made,   that  we 
might  investigate  the  relation  between  the  variety  of 
germs  present  and  the  tendency  to  spread. 


A  STUDY  OF  SERIAL  CROSS-SECTIONS,  WITH  PARTICULAR 
RELATION  TO  THE  FASCIAL  SPACES. 

That  we  may  follow  the  study  of  the  serial  cross- 
sections  with  more  understanding,  the  following  facts 
should  be  noted:  It  is  known  that  five  spaces  may 
be  found  in  the  hand;  the  information  about  them, 
however,  has  been  very  indefinite.  The  result  of  our 
study  shows  that  upon  the  palmar  surface  we  have 
three  distinct  chambers,  not  communicating  in  any  way 
with  each  other,  and  to  these  are  given  the  names 
thenar,  hypothenar,  and  middle  palmar  spaces  re- 
spectively. Certain  channels  will  be  found  which  lead 
directly  into  them.  Certain  structures  along  which 
pus  can  pass  will  be  noted  lying  in  juxtaposition. 
Again,  minor  anatomical  chambers  will  be  noted;  these, 
however,  need  little  or  no  consideration  from  a  surgical 
standpoint,  since  they  are  unimportant,  not  likely  to 
become  infected  separately,  and  if  they  do,  they  will 
rupture  into  one  of  the  larger  pockets. 

Upon  the  dorsum  two  areas  will  be  found,  in  each  of 
which  pus  can  accumulate  to  the  exclusion  of  the  other. 


84 


METHODS  OF  STUDY  IN  GENERAL 


To  these  are  given  the  names  dorsal  subcutaneous 
space  and  dorsal  subaponeurotic  space.  We  shall  find 
that  while  the  pus  may  lie  at  various  levels  in  the 
subcutaneous  tissue,  from  an  anatomical  standpoint, 
yet  for  surgical  purposes  any  subdivision  of  this  space 
is  unnecessary  and  confusing. 

Section  I.  Beginning  with  a  cross-section  which 
lies  just  distal  to  the  web  of  the  fingers,  we  note  the 
following  facts:  The  index  finger  is  slightly  different 


FIG.  19 


SC5 


FT 


Cross-section  No.  I. — DSAS,  dorsal  subaponeurotic  space;  DV  and  N, 
digital  vessels  and  nerves;  ECT,  extensor  communis  tendon;  FT,  flexor 
tendon;  PP,  proximal  phalanx;  SCS,  subcutaneous  space;  SS,  synovial 
sheath.  The  tendon  sheaths  are  shown  in  red. 

from  the  middle  and  ring  fingers  in  that  the  space 
which  is  most  superficial,  and  which  we  will  call  "the 
subcutaneous  space, "  does  not  extend  around  the  entire 
finger,  as  do  the  others,  but  at  the  radial  side  the  peri- 
fascial  space  tissue  is  so  dense  as  to  obliterate  it.  It 
will  be  noted  that  this  space  is  deep,  and  that  between 
it  and  the  skin  is  to  be  found  considerable  tissue  which 
is  rather  dense  and  does  not  lend  itself  readily  to  the 
spread  of  pus,  which  in  this  area  is  more  likely  to  come 
to  the  surface  or  infect  the  space  above  mentioned, 


A   STUDY  OF  SERIAL  CROSS-SECTIONS  85 

where  it  will  have  little  difficulty  in  spreading  proxi- 
mally  or  distally  (Fig.  19). 

The  little  ringer  corresponds  with  the  index  finger 
in  that  the  space  is  obliterated  upon  its  ulnar  side. 
Between  the  tendon  and  the  bone  in  each  of  the  four 
fingers  there  is  a  second  space,  and  to  this  we  will 
give  the  name  of  "dorsal  subaponeurotic  space  of  the 
finger,"  for  upon  each  side  of  the  tendon  a  dense  sheet 
of  tissue  is  given  off,  which  unites  firmly  with  the 
periosteum  at  each  side.  Upon  the  flexor  surface  are 
found  the  flexor  tendons  in  their  synovial  sheaths, 
which  sheaths  are  so  closely  united  to  the  periosteum 
that  no  definite  free  spaces  can  be  found. 

The  importance  of  the  close  attachment  of  the  tendon 
sheath  to  the  bone  will  be  brought  out  when  discussing 
tendon-sheath  infection  in  relation  to  the  frequency 
of  osteomyelitis  secondary  to  this  trouble. 

In  my  experience  the  "subcutaneous  space"  men- 
tioned above  is  frequently  the  seat  of  an  abscess,  and 
care  should  be  taken  not  to  mistake  it  for  a  tendon- 
sheath  infection. 

The  spaces  above  mentioned  all  pass  through  this 
serial  section  into  the  next,  the  second  cross-cut  being 
made  through  the  epiphysis  of  the  proximal  phalanx. 

Section  II.  In  this  section  the  salient  points  may 
be  pointed  out  briefly,  so  that  we  can  retain  a  com- 
posite picture  with  that  which  has  just  been  described 
(Fig.  20). 

The  subcutaneous  space  is  continuous  with  that  in 
Section  I ;  at  the  volar  side,  however,  we  note  a  begin- 
ning division  into  two — palmar  and  dorsal. 

The  subaponeurotic  space  is  also  continuous  and 
the  interossei  muscles  (IM)  begin  to  appear — one 
part  attached  to  the  periosteum  and  one  part  to  the 
dorsal  aponeurotic  sheet.  More  important  still,  we 
see  the  beginning  of  the  lumbrical  muscles  (LM),  and 


86 

note  particularly  the  relation  of  this  muscle  to  the  sub- 
cutaneous space,  especially  in  the  third  finger. 

The  flexor  tendons  are  still  covered  by  their  synovial 
sheaths. 

Ask  yourself  where  pus  would  land  if  it  followed 
down  along  the  lumbrical  muscle  from  the  palm.  As 
we  follow  these  spaces  into  the  next  section,  we  will 
see  that  the  subcutaneous  spaces  upon  the  abutting 
sides  of  the  fingers  merge  into  each  other;  that  is  to 

FIG.  20 


Cross-section  No.  II. — Through  epiphysis  of  proximal  phalanx.  DSAS, 
dorsal  subaponeurotic  space;  DSCS,  dorsal  subcutaneous  space;  DV  and  N, 
digital  vessels  and  nerves;  ECT,  extensor  communis  tendon;  EPP,  epiphysis 
proximal  phalanx;  FT,  flexor  tendon;  IM,  interossei  muscles;  LM,  lumbrical 
muscle;  SS,  synovial  sheath.  The  tendon  sheaths  are  shown  in  red. 

say,  the  subcutaneous  spaces  of  the  ulnar  side  of  the 
index  finger  and  the  radial  side  of  the  middle  finger 
join  at  the  web,  being  in  close  relation  to  the  lumbrical 
muscles;  slightly  proximal  to  this,  as  will  be  seen  in 
the  next  serial  section,  the  space  is  obliterated  between 
the  fingers,  and  only  a  small  part  remains  upon  the 
dorsum  of  each  finger.  It  is  in  connection  with  the 
space  about  the  lumbrical  muscle  in  the  palm,  however, 
so  that  pus  may  spread  from  the  palm  downward  into 


A  STUDY  OF  SERIAL  CROSS-SECTIONS 


87 


this  space  and  thus  point  on  the  dorsum.  (For  sche- 
matic drawing  showing  this,  see  p.  437.)  The  dorsal 
subaponeurotic  space  is  obliterated  in  this  section, 
i.  e.,  at  the  joint. 

Section  III.  The  distal  surface  of  the  third  serial 
section  is  seen  upon  a  cut  0.5  cm.  proximal  to  the  joint 
(Fig.  21).  Note  here: 

FIG.  21 


Cross-section  No.  III. — Proximal  to  metacarpophalangeal  joint.  DSAS, 
dorsal  subaponeurotic  space;  DSCS,  dorsal  subcutaneous  space;  DT,  dense 
fibrous  tissue;  DV  and  N,  digital  vessels  and  nerves;  ECT,  extensor  com- 
munis  tendon;  FT,  fiexor  tendon;  IM,  interossei  muscles;  LM,  lumbrical 
muscle;  MB,  metacarpal  bone;  SB,  sesamoid  bone;  55,  synovial  sheath. 
Tendon  sheaths  are  shown  in  red  and  the  boundaries  of  the  lumbrical  spaces 
in  blue. 

The  absence  of  the  subaponeurotic  space,  except  for 
small  diverticula  lying  between  the  two  parts  of  the 
interossei  muscle. 

The  absence  of  the  subcutaneous  space  between  the 
fingers.  It  is  continued,  however,  in  the  dorsal  sub- 
cutaneous space  (DSCS)  and  the  space  about  the 
lumbrical  muscle  (LM). 

That  the  lumbrical  muscle  lies  in  a  sheath  of  its 


88 


METHODS  OF  STUDY  IN  GENERAL 


own,  as  it  were.  This  communicates  with  the  subcu- 
taneous space  of  the  fingers,  and  should  be  followed 
carefully  into  the  palm. 

The  dense  layer  of  tissue  that  crosses  the  whole 
section  lying  around  and  over  the  tendon  sheaths  and 
under  the  lumbrical  muscle. 

That  the  flexor  tendons  are  surrounded  by  their 
sheaths. 

FIG.  22 


Cross-section  No.  IV. — Two  cm,  proximal  to  joint.  ATP,  adductor  trans- 
versus  pollicis;  DB,  digital  branch,  DSAS,  dorsal  subaponeurotic  space; 
DSCS,  dorsal  subcutaneous  space;  DT,  dense  fibrous  tissue;  ECT,  extensor 
communis  tendon;  FLP,  flexor  longus  pollicis  in  its  synovial  sheath;  FT, 
flexor  tendon;  IM,  interossei  muscles;  LM,  lumbrical  muscle;  M,  metacarpal 
bone;  MFC,  middle  flexion  crease;  MPS,  middle  palmar  space;  RI,  radialis 
indicis;  SS,  synovial  sheath;  TS,  thenaj  space.  The  tendon  sheaths  are  shown 
in  red  and  the  lumbrical  spaces  in  blue.  Note  the  beginning  of  the  middle 
palmar  space. 

The  spaces  are  all  obliterated  in  passing  either 
through  this  section  or  the  previous  one,  except  the 
synovial  space  about  the  flexor  tendons,  that  about 
the  lumbrical  muscles,  and  the  slight  channel  on  the 
dorsum,  above  noted,  passing  between  the  subcu- 
taneous tissue  of  the  finger  and  the  hand. 


A  STUDY  OF  SERIAL  CROSS-SECTIONS 


89 


The  surgical  application  of  this  will  be  brought  out 
later. 

Section  IV.  The  fourth  cross-section  lies  two  cen- 
timeters above  the  joint  (Fig.  22). 

FIG.  23 


L  

Cross-section  No.  V. — 3$  cm.  proximal  to  joint.  A  TP,  adductor  trans- 
versus  pollicis;  DIM,  dorsal  interosseous  membrane;  DSAS,  dorsal  sub- 
aponeurotic  space;  DSCS,  dorsal  subcutaneous  space;  ECT,  extensor  com- 
munis  tendon;  FLP,  flexor  longus  pollicis  in  its  synovial  sheath;  FT,  flexor 
tendon;  H M,  hypothenar  muscles  with  intermuscular  spaces;  IM,  interossei 
muscles;  75,  space  between  adductor  transversus  and  first  dorsal  interosseous; 
IV,  interosseous  vessels  and  nerve;  LM,  lumbrical  muscle;  M,  metacarpal 
bone;  MPS,  middle  palmar  space;  PIM,  palmar  interosseous  membrane; 
RI,  radialis  indicis;  TS,  thenar  space;  UB,  ulnar  bursa;  UV  and  N,  ulnar 
vessels  and  nerve;  V,  vein.  The  tendon  sheaths  are  shown  in  red  (ulnar 
bursa  and  radial  bursa) .  The  outline  of  the  middle  palmar  and  thenar  spaces 
are  shown  in  blue. 


The  dorsal  subaponeurotic  spaces,  which  were  oblit- 
erated at  the  joint,  are  beginning  again  between  each 
tendon  and  the  corresponding  bone. 


90  METHODS  OF  STUDY  IN  GENERAL 

The  dorsal  subcutaneous  spaces  approximate  each 
other. 

The  palmar  tissue  is  still  dense,  with  no  free  passages 
except  those  about  the  lumbrical  muscles  and  those 
along  the  sheaths  of  the  tendons  which  are  still  present, 
but  begin  to  be  obliterated  as  they  pass  through  this 
serial  section. 

As  yet  no  space  has  appeared  into  which  pus  would 
extend  if  it  were  to  pass  proximally  along  these  syno- 
vial  sheaths.  We  note,  however,  that  a  small  space 
has  appeared  just  above  the  small  piece  of  adductor 
transversus  muscle,  which  will  become  the  thenar 
space  (TS). 

Now  let  us  imagine  ourselves  following  through  this 
serial  section  into  the  next.  The  free,  open  spaces 
of  the  hand  appear  suddenly,  the  synovial  sheaths  of 
the  tendons  become  obliterated  after  entering  them, 
the  lumbrical  muscles  join  the  tendons,  and  the  adduc- 
tor transversus,  which  is  the  keynote  to  the  thenar 
space,  begins  to  assume  its  characteristic  relations. 

Section  V.  If  we  cut  across  about  three  centimeters 
above  the  joint,  we  find  the  following,  which  is  well 
represented  in  Fig.  23. 

THE  MIDDLE  PALMAR  SPACE. 

There  is  a  large,  free  space  with  few  fibrous  septa 
extending  from  the  middle  metacarpal  bone  to  the 
radial  side  of  the  metacarpal  bone  of  the  little  finger. 
It  is  bounded  dorsally  by  a  thin  fibrous  sheet  which 
overlies  the  anterior  interosseous  membrane  and  the 
interossei  muscles;  upon  its  palmar  side  is  a  second 
thin  sheet  separating  it  from  the  tendons  and  the  lum- 
brical muscles  of  the  little  and  ring  fingers.  The  space 
is  limited  upon  its  ulnar  side  by  dense,  fibrous  tissue, 
and  upon  its  radial  side  by  a  dense,  fibrous  sheet 


THE  THENAR  SPACE  91 

which  lies  over  the  adductor  transversus.  This  space 
is  probably  the  most  important  in  the  hand,  and  to 
it  is  given  the  name  of  "Middle  Palmar  Space." 

If  we  were  to  note  the  layers  of  tissue  through  the 
middle  of  the  hand,  going  from  the  palm  to  the  dorsum, 
they  would  be  as  follows: 

1.  Epidermis. 

2.  Dermis. 

3.  Firmly  meshed  subdermal  connective  tissue. 

4.  Palmar  aponeurosis. 

5.  Loose  mesh  of  connective  tissue,   in  which  lie 
(a)   vessels;    (&)    tendons  with   lumbrical   muscles,   or 
endings  of  the  synovial  sheaths. 

6.  Anterior  middle  palmar  sheet. 

7.  Middle  Palmar  Space. 

8.  Posterior  middle  palmar  sheet. 

9.  Vessels. 

10.  Palmar  interosseous  membrane,  extending  from 
bone  to  bone. 

11.  Interossei  muscles. 

12.  Posterior   interosseous   membrane. 

13.  Dorsal    subaponeurotic    space    filled    with    thin 
meshed  connective  tissue  and  vessels. 

14.  Dorsal  aponeurosis  and  tendons. 

15.  Dorsal  subcutaneous  space,  with  loose  connec- 
tive tissue. 

16.  Dermis. 

17.  Epidermis. 

THE  THENAR  SPACE. 

Upon  the  radial  side  we  note  the  large  mass  of  the 
adductor  transversus,  and  upon  its  palmar  side  is 
shown  a  large  space  extending  from  the  metacarpal 
bone  of  the  middle  finger  over  the  muscle  to  the  radial 
side  of  the  hand,  stopping,  however,  at  the  middle 
of  the  radial  side,  at  about  the  level  of  the  palmar 


92  METHODS  OF  STUDY  IN  GENERAL 

surface  of  the  bones;  or,  in  other  words,  being  L-shaped 
in  cross-section.  It  will  be  seen  later  that  this  limita- 
tion is  of  importance,  since  it  prevents  injection  masses 
from  passing  freely  to  the  dorsum  of  the  hand,  or 
vice  versa.  This  space  is  known  as  the  "  Thenar  Space. " 
Upon  its  palmar  side  there  is  a. strong  layer  of  tissue, 
blending  into  the  dense  tissue  of  the  palm,  and  between 
this  dense  palmar  tissue  and  the  space  lie  the  tendon 
and  lumbrical  muscle  of  the  index  finger.  Over  the 
adductor  muscle  is  a  thin  layer  of  tissue  or  perimuscular 
sheath. 

The  middle  palmar  and  thenar  spaces  are  the  two 
most  important  spaces  in  the  hand,  and  it  is  well  to 
note  their  relations  to  each  other  and  to  adjacent 
structures.  They  will  be  taken  up  later,  and  a  com- 
posite picture  made  from  the  fragmentary  description 
noted  here  and  in  the  following  serial  sctions. 

Upon  the  dorsum  the  dorsal  subcutaneous  and  sub- 
aponeurotic  spaces  are  well  shown. 

The  synovial  sheaths  have  entirely  disappeared 
except  for  a  small  prolongation  along  the  little  finger 
tendon  (UB)  and  that  about  the  flexor  longus  pollicis 
(FLP).  The  tendon  sheaths  of  the  three  tendons 
were  obliterated  while  passing  through  this  section. 
The  ulnar  bursa  (UB),  however,  is  seen  to  lie  in 
juxtaposition  to  the  middle  palmar  space  as  do  the 
tendon  sheaths  of  the  middle  and  ring  finger  distal  to 
this  section.  The  tendon  sheath  of  the  index  finger  is 
in  close  connection  with  the  thenar  space  (TS). 

Section  VI  (Fig.  24).  This  serial  section  is  taken 
through  the  distal  part  of  the  thenar  eminence,  and 
thus  shows  the  metacarpal  bone  of  the  thumb  in  cross- 
section.  Here  we  note  the  great  relative  size  of  the 
thenar  space  (TS),  and  yet  it  is  all  upon  the  radial 
side  of  the  middle  metacarpal.  The  lumbrical  muscle 
and  index  tendon  are  separated  from  it  by  a  much 


THE  THENAR  SPACE 


93 


thinner  septum  than  in  the  previous  section.  The 
tendon  of  the  flexor  longus  pollicis  appears  here 
surrounded  by  its  synovial  sheath. 

FIG.  24 


DSCS     P1M  1M 


(  :!v    - 


IT5 


Cross-section  No.  VI. — Through  distal  part  of  thenar  area.  A  TP,  adductor 
trans  versus  pollicis;  DIA,  dorsalis  indicis  artery;  DP  A,  deep  palmar  arch 
—digital  branches  beginning;  DSAS,  dorsal  subaponeurotic  space;  DSCS, 
dorsal  subcutaneous  space;  ECT,  extensor  communis  tendon;  FLP,  flexor 
longus  pollicis  in  its  synovial  sheath;  HM,  hypothenar  muscles  with  inter- 
muscular  spaces;  IM,  interossei  muscles;  ITS,  indefinite  thenar  spaces; 
IS,  space  between  adductor  transversus  and  first  dorsal  interosseous ;  LM, 
lumbrical  muscle;  MA  and  N,  median  artery  and  nerve;  M,  metacarpal  bone; 
MPS,  middle  palmar  space;  PF,  palmar  fascia;  PIM,  palmar  interosseous 
membrane;  TS,  thenar  space;  TM,  thenar  muscles;  TMF,  tendon  of  middle 
finger;  UB,  ulnar  bursa;  UV  and  N,  ulnar  vessels  and  nerves.  The  ulnar 
bursa,  radial  bursa,  and  an  intermediate  tendon  sheath  are  shown  in  red.  The 
boundaries  of  the  middle  palmar  and  thenar  spaces  are  shown  in  blue. 


The  middle  palmar  space  is  much  smaller  and  still 
lies  under  the  group  of  tendons  of  the  middle,  ring, 
and  little  fingers.  Upon  the  ulnar  side  of  this  group 
we  see  the  ulnar  synovial  bursa  in  juxtaposition  to  the 
space,  yet  the  septum  between  them  must  be  strong 
since  the  injection  masses  in  this  bursa,  noted  later, 


94  METHODS  OF  STUDY  IN  GENERAL 

have  a  greater  tendency  to  rupture  into  the  forearm 
than  into  this  space. 

Upon  the  dorsum  we  still  find  our  subaponeurotic 
and  subcutaneous  spaces,  while  over  the  thenar  area  the 
subcutaneous  tissue  is  also  lax,  and  either  of  the  two 
former  spaces  can  be  made  to  communicate  with  it. 

The  deep  palmar  arch  (DP A)  appears  in  this 
section,  and  its  relation  to  the  middle  palmar  space  and 
the  synovial  sheath  should  be  noted.  We  see  that  there 
is  not  much  danger  of  injuring  it  if  care  is  taken  in 
operating. 

In  the  cases  examined  the  flexor  longus  pollicis 
with  its  tendon  sheath  is  separated  from  the  thenar 
space  by  a  considerable  amount  of  tissue,  and  while 
rupture  from  it  into  the  space  is  possible  (particularly 
in  those  cases  accompanied  by  inflammatory  destruc- 
tion), yet  it  would  be  more  likely  to  rupture  at  the 
upper  end  of  the  synovial  sac  into  the  cellular  tissue  of 
the  forearm.  Experimental  evidence  to  support  this 
will  be  brought  forward  later  (see  pp.  126  and  127). 

Section  VII  (Fig.  25).  In  the  seventh  section, 
taken  through  the  base  of  the  palm,  the  middle  palmar 
space  and  the  thenar  space  are  seen  to  have  shrunk 
into  insignificance.  They  lie  close  together  under  the 
group  of  tendons,  the  middle  palmar  space  being  more 
superficial.  They  are  still  separated  by  a  thin  sheet, 
however,  in  those  specimens  examined. 

One  or  two  indefinite  spaces  are  present  about  the 
thenar  region.  They  are  of  little  importance,  however, 
except  to  note  that  they  are  present  between  the 
groups  of  muscles,  and  localized  infection  can  occur 
in  them  under  exceptional  circumstances. 

The  dorsal  spaces  remain  the  same,  except  that  the 
subaponeurotic  is  more  constricted. 

The  tendon  sheaths  are  seen  in  four  places — the 
ulnar  bursa  (UB),  the  sheath  about  the  flexor  longus 


THE  HYPOTHENAR  SPACE 


95 


pollicis  (FLP),  and  the  two  intermediate  sheaths 
about  the  superficial  tendons  in  juxtaposition  to  the 
ulnar  bursa.  These  will  be  discussed  later  (see  pp. 
109  and  no). 


M.N. 


FLP 


Cross-section  No.  VII. — DSAS,  dorsal  subaponeurotic  space;  DSCS, 
dorsal  subcutaneous  space;  ECT,  extensor  communis  tendon;  FLP,  flexor 
longus  pollicis  in  its  synovial  sheath;  FT,  flexor  tendon;  HM,  hypothenar 
muscles  with  intermuscular  spaces;  IS,  space  between  adductor  transversus 
and  first  dorsal  interosseous;  M,  metacarpal  bone;  MN  and  V,  median  nerve 
and  vessels;  MPS,  middle  palmar  space;  RA,  radial  artery;  SS,  synovial 
sheath;  TM,  thenar  muscles;  TS,  thenar  space;  UB,  ulnar  bursa;  UV  and  N, 
ulnar  vessels  and  nerve.  The  ulnar  and  radial  bursas  and  the  intermediate 
tendon  sheaths  are  outlined  in  red  and  the  middle  palmar  and  thenar  spaces 
in  blue. 


THE  HYPOTHENAR  SPACE. 

Nothing  as  yet  has  been  said  of  the  hypothenar  area, 
since  it  was  desirable  to  avoid  confusion.  However, 
a  glance  at  this  section,  and  at  those  which  have 


96 


METHODS  OF  STUDY  IN  GENERAL 


preceded,  shows  very  clearly  that  while  it  is  possible 
for  pus  to  accumulate  in  the  intermuscular  septa  of 
this  space,  yet  it  would  be  absolutely  localized  here, 


FIG.  26 


EMfl 


ECU 


Cross-section  No.  VIII. — DSCS,  dorsal  subcutaneous  space;  EC,  extensor 
communis;  ECRB,  extensor  carpi  radialis  brevior;  ECRL,  extensor  carpi 
radialis  longior;  ECU,  extensor  carpi  ulnaris;  EMD,  extensor  minimi  digiti; 
EPTP,  extensor  primi  internodii  pollicis;  ESIP,  extensor  secundi  internodii 
pollicis;  FLP,  flexor  longus  pollicis  in  its  synovial  sheath;  HM,  hypothenar 
muscles  with  intermuscular  spaces;  M N  and  V,  median  nerve  and  vessels; 
PL,  palmaris  longus;  PMPS,  prolongation  of  middle  palmar  space;  RV  and 
N,  radial  vessels  and  nerves;  SS,  synovial  sheaths;  TM,  thenar  muscles;  UB, 
ulnar  bursa;  UV  and  N,  ulnar  vessels  and  nerve.  The  ulnar  bursa,  radial 
bursa,  and  intermediate  sheaths  are  shown  in  red.  The  small  prolongation 
of  the  middle  palmar  and  thenar  spaces  in  blue. 

and  would  spread  to  the  surface.  It  would  not  enter 
either  the  middle  palmar  space  or  the  ulnar  synovial 
bursa.  Such  infections  would  be  of  little  surgical 
interest,  owring  to  their  localized  nature. 


THE  MIDDLE  PALMAR  AND  THENAR  SPACES     97 

Section  VIII  (Fig.  26).  In  the  eighth  section,  taken 
at  the  wrist,  the  middle  palmar  and  thenar  spaces 
can  still  be  found,  but  they  are  so  small  as  to  be 
of  little  practical  importance,  since  any  inflammation 
in  them  would  probably  be  followed  by  closure. 
Their  behavior  under  forcible  injection  will  be  noted 
later. 

While  it  might  be  possible  by  forcible  dissection  to 
produce  a  dorsal  subaponeurotic  space,  yet  it  should 
not  be  described  as  being  present. 

The  dorsal  subcutaneous  space  can  be  demonstrated, 
but  it  is  more  difficult  to  do  so  here  than  in  the  previous 
sections,  since  more  of  the  fibers  tend  to  intermingle 
from  layer  to  layer. 

The  synovial  sheaths  about  the  dorsal  tendons  also 
appear  in  this  section. 


DISCUSSION  OF  THE  RELATIONS  OF  THE  MlDDLE  PALMAR  AND  THENAR 

SPACES. 

The  inter-relation  of  the  middle  palmar  and  thenar 
spaces  is  of  very  great  interest  to  the  surgeon,  and  to 
understand  it  the  roof  and  floor  of  the  two  spaces  must 
be  discussed  together.  They  are  separated  from  each 
other  at  the  middle  metacarpal  bone  by  firm  septa, 
so  that  neither  one  communicates  with  the  other,  nor 
does  either  overlap  to  the  other  side  of  this  bone.  The 
tendons  of  the  third  and  fourth  fingers,  with  their 
lumbrical  muscles,  lie  just  above  the  middle  palmar 
space,  separated  from  it  by  only  a  thin,  indefinite 
membrane,  while  upon  the  palmar  side  of  this  group 
are  a  few  indefinite  spaces;  but  pus  must  pass  around 
the  tendons  to  their  dorsal  surface  and  rupture  into 
the  middle  palmar  space,  since  in  every  other  direction 
firm  tissue  is  found.  Such  a  course  might  be  followed 
in  an  infection  passing  upward  along  the  lumbrical 

7 


98  METHODS  OF  STUDY  IN  GENERAL 

muscles.  If  it  follows  along  the  synovial  sheath  of  the 
ring  finger,  and  finally  ruptures  from  the  proximal 
blind  end,  it  will  pass  ultimately  into  this  space.  The 
same  holds  true  for  the  tendon  sheath  of  the  little 
finger  in  those  cases  in  which  it  is  separated  from 
the  ulnar  bursa.  To  the  ulnar  side  of  the  tendon  of 
the  little  finger  is  seen  the  small  synovial  space  repre- 
senting the  continuation  of  the  synovial  sheath  of  the 
little  finger  into  the  synovial  sheath  of  the  tendons 
above,  known  as  the  ulnar  bursa. 

It  will  be  seen  that  the  lumbrical  muscle  and  tendon 
of  the  index  finger  occupy  the  same  relative  position 
to  the  thenar  space  that  the  third  and  fourth  do  to 
the  middle  palmar  space,  with  this  exception,  that  in 
those  hands  which  have  been  examined  the  sheet  of 
tissue  separating  it  from  the  thenar  space  is  somewhat 
firmer;  still,  it  is  not  so  dense  as  that  upon  the  other 
three  sides,  and  here  also,  then,  it  must  communicate 
with  the  space  below  it. 

The  lumbrical  muscle  and  tendon  of  the  middle 
finger  in  Section  VI  occupy  an  intermediary  place 
between  the  two  spaces,  but  in  the  previous  section 
they  will  be  seen  to  lie  over  the  middle  palmar  space, 
at  which  site  the  enveloping  fascia  is  much  thinner, 
so  that  we  would  have  reasons  to  believe,  from  an 
anatomical  standpoint,  that  pus  spreading  along  this 
tendon  would  communicate  more  easily  with  the  middle 
palmar  space,  and  experimental  injections  of  the 
synovial  sheath  substantiate  this  reasoning. 

We  have  now  discussed  all  of  the  relations  of  these 
spaces  except  the  floor,  or  dorsal  surface,  and  the 
proximal  prolongation.  The  latter  we  will  speak  of 
in  the  chapter  dealing  with  anatomy  of  the  forearm. 
Concerning  the  floor,  however,  it  is  well  to  mention 
several  things.  Owing  to  the  closed  nature  of  these 
pockets,  it  is  customary  for  clinicians  to  draw  atten- 


THE  MIDDLE  PALMAR  AND  THENAR  SPACES     99 

tion  to  the  frequency  of  rupture  from  them,  through 
between  the  bones,  to  the  dorsal  surface. 

In  the  middle  palmar  space  the  floor  is  composed 
of  a  very  thin  fascial  layer,  through  which  pus  could 
rupture  easily,  were  it  not  for  the  support  given  it 
by  the  interossei  muscles  and  the  interosseous  mem- 
brane, upon  which  it  lies.  Should  inflammatory 
destruction  of  this  sheet  arise,  however,  or  rupture 
ensue,  the  interossei  muscles  would  still  offer  a  slight 
resistance,  for  there  is  no  distinct  channel  leading  to 
the  dorsum,  although  the  intermuscular  septa  do  tend 
in  that  direction.  Having  come  through  these,  how- 
ever, the  pus  would  then  meet  the  septum  passing 
from  one  bone  to  the  other  upon  the  dorsal  surface  of 
the  interossei  muscles.  If  the  pus  meets  and  over- 
comes the  various  obstructions,  which  it  might  do 
in  chronic  and  exceptional  cases,  it  would  then  lie 
beneath  the  tendons  upon  the  dorsal  surface,  or  in  the 
dorsal  subaponeurotic  space. 

Now  let  us  go  back  to  the  thenar  space  and  its  floor, 
or  dorsal  wall.  This  is  slightly  more  complex,  in  that 
the  muscular  masses  making  up  the  floor  confuse  us. 
For  the  most  part  it  is  made  up  of  the  adductor 
transversus  and  the  adductor  obliquus,  and  in  those 
cases  where  there  is  little  tension  upon  the  contents  it 
would  be  limited  dorsally  by  them  and  the  thin  sheet 
of  fascia  over  the  muscles.  Upon  the  other  hand,  if 
the  tension  were  increased,  it  would  be  very  easy  for 
the  contents  of  the  cavity  to  pass  between  these 
muscles  and  come  to  lie  upon  the  dorsal  surface  of  the 
adductor  transversus.  That  is  to  say,  it  would  come 
against  the  first  dorsal  interosseous  upon  the  dorsum 
of  the  thenar  region  about  on  a  level  with  the  meta- 
carpophalangeal  joint  of  the  thumb,  and  thus,  if  there 
were  any  inflammatory  action  present,  spread  to  the 
cutaneous  tissue  at  the  \veb;  or,  if  the  dorsal  inter- 


100  METHODS  OF  STUDY  IN  GENERAL 

osseous  muscle  were  unimportant,  in  the  dorsal  sub- 
cutaneous tissue  of  the  thenar  region.  Experimental 
evidence  will  be  adduced  later  to  prove  this  can  occur. 


We  note  that  we  have  six  important  fascial  spaces 
with  their  tributaries  in  which  pus  can  accumulate. 

1.  The  dorsal  subcutaneous,  which  is  an  extensive 
area    of    loose    tissue,    without    definite    boundaries, 
allowing  pus  to  spread  over  the  entire  dorsum  of  the 
hand. 

2.  The  dorsal  subaponeurotic,  limited  upon  its  sub- 
cutaneous  side   by   the   dense   tendinous   aponeurosis 
of  the  extensor  tendons,  upon  the  deep  side  by  the 
metacarpal  bones,   having  the  shape  of  a  truncated 
cone,  with  the  smaller  end  at  the  wrist  and  the  broader 
at  the  knuckle.    Laterally  the  aponeurotic  sheet  shades 
off  into  the  subcutaneous  tissue. 

3.  The  hypothenar  area,  a  distinctly  localized  space. 

4.  The  thenar  space,  occupying,  approximately,  the 
area  of  the  thenar  eminence.     Superficially  its  internal 
boundary  is  indicated  by  the  adduction  crease  of  the 
thumb.     It  lies  entirely  upon  the  radial  side  of  the 
middle  metacarpal.      It  should  be  remembered   that 
this  space  lies  deep  in  the  palm,  just  above  the  adductor 
transversus. 

5.  The  middle  palmar  space,  with  its  three  diver- 
ticula  below  along  the  lumbrical  muscles,  limited  by 
the   middle   metacarpal    bone    upon    the    radial    side, 
overlapped  by  the  ulnar  bursa  upon  the  ulnar  side,  and 
separated  from  the  thenar  space  by  a  partition  which 
is  very  firm  everywhere  except  at  the  proximal  end, 
where  it  is  rather  thin.    A  small  isthmus  can  be  found 
leading  from  the  proximal  end  of  the  space  under  the 
tendons  and  ulnar  bursa  at  the  wrist  into  the  forearm. 


-,  101r  J  r ' 

6.  The  web  space,  an  area  orioose  connective  tissue 
between  the  bases  of  the  fingers,  with  prolongations 
distally  into  the  subcutaneous  tissue  at  the  sides  of  the 
fingers,  and  proximally  into  the  subcutaneous  tissue 
of  the  dorsum  on  the  dorsal  surface  and  into  the 
connective-tissue  spaces  around  the  lumbrical  muscle 
on  the  palmar  surface.  The  corroboration  of  our 
statement  as  to  the  outlines  of  these  spaces  will  be 
brought  out  in  the  chapter  upon  experimental  injec- 
tions (Chapter  IX). 


TcO    nO  3t?3JJOO 
c   £  chAIOll-YI-i's 


CHAPTER    VIII. 

THE  TENDON   SHEATHS:    A  DISCUSSION   OF  THEIR 

ANATOMICAL  DISTRIBUTION  AND  RELATIONS, 

WITH  SURGICAL  DEDUCTIONS. 

FROM  a  consideration  of  the  cross-sections  we  have 
described  in  the  previous  chapters  it  is  possible  to 
give  a  composite  picture  of  the  various  tendon  sheaths 
from  an  anatomical  and  surgical  standpoint.  In  the 
following  description  the  well-known  anatomical  points 
which  have  no  bearing  on  the  subject  in  hand  will  not 
be  dealt  with.  It  is  my  intention  to  emphasize  those 
facts  which  will  aid  us  in  understanding  the  course 
an  infection  will  pursue,  and  will  point  to  the  proper 
course  of  treatment.  Therefore,  before  reading  this  one 
should  have  a  clear  conception  of  the  anatomy  of  the 
six  fascial  spaces  described  in  the  previous  chapter. 

The  particular  relation  of  the  sheaths  to  the  six 
fascial  spaces  will  be  emphasized  in  the  chapter  deal- 
ing with  experimental  injections  (Chapter  IX).  These 
will  also  serve  to  corroborate  the  anatomical  state- 
ments made  here. 

9 

SHEATHS  UPON  THE  FLEXOR  SURFACE. 

From  a  surgical  standpoint,  the  sheaths  upon  the 
flexor  surface  are  the  most  important.  The  anatomy 
of  these  may  be  discussed  under  four  heads:  (i)  The 
tendon  sheaths  for  the  index,  middle,  and  ring  fingers; 
(2)  the  tendon  sheath  for  the  thumb  with  its  prolonga- 
tion in  the  hand  (radial  bursa);  (3)  the  tendon  sheath 
of  the  little  finger  and  its  prolongation  in  the  palm 
(ulnar  bursa) ;  (4)  the  communications  between  these 
various  sheaths. 


SHEATHS  OF  INDEX,  MIDDLE,  AND  RING  FINGERS     103 


THE  SHEATHS  OF  THE  INDEX,  MIDDLE,  AND  RING  FINGERS. 

These  begin  just  distal  to  the  distal  interphalangeal 
joint  and  extend  into  the  palm,  approximately  a 
thumb's  breadth  proximal  to  the  web;  or  the  point  of 
extension  can  be  designated  by  drawing  a  line  between 
the  end  of  the  proximal  palmar  crease  at  the  base  of 
the  index  finger  and  the  end  of  the  distal  palmar  crease 
at  the  base  of  the  little  finger.  This  line  represents  the 
approximate  extension  of  these  sheaths  into  the  palm. 
It  will  be  seen  by  noting  Fig.  22  that  at  the  distal 
portion  of  the  palm  there  is  a  sheet  of  dense  tissue 
enclosing  the  tendon  sheaths  and  lumbrical  muscles. 
The  sheaths  extend  one-fourth  inch  proximal  to  this 
into  the  loose  palmar  tissue.  This  fact  is  of  consider- 
able importance  from  a  surgical  standpoint  (see  pp. 
118  and  168). 

While  passing  through  the  dense  tissue  mentioned 
above,  these  sheaths  have  on  either  side  the  space 
called  the  lumbrical  canal,  through  which  pass  the 
lumbrical  muscles  and  digital  branches  of  the  arteries 
and  nerves  (Fig.  21).  This  is  also  of  surgical  impor- 
tance (see  pp.  183  and  216). 

As  we  pass  distally,  we  find  considerable  tissue 
between  the  metacarpophalangeal  joint  and  the  sheath 
proper,  while  more  distally,  as  we  come  to  the  base 
of  the  proximal  phalanx,  we  note  that  the  sheath 
approaches  the  bone  and  is  in  close  relation  with  the 
loose  connective  tissue  going  entirely  around  the  bone. 
The  surgical  importance  of  this  will  be  brought  out 
later. 

At  the  proximal  interphalangeal  joint  (Fig.  132)  we 
find  considerable  tissue  between  the  sheath  and  the 
joint,  while  over  the  base  of  the  middle  phalanx,  i.  e., 
at  the  epiphyseal  line  (Fig.  27),  there  is  little  or  no 


104  THE  TENDON  SHEATHS 

tissue  between  the  sheath  and  the  bone.  From  this 
point  distally  the  relation  to  the  bone  is  not  so  inti- 
mate. At  the  distal  end  the  relation  of  the  structures 
can  be  seen  by  studying  Fig.  2.  (For  surgical  appli- 
cation, see  p.  164  and  Chapter  XXVIII.) 

FIG.  27 


Cross-section  through  the  epiphysis  of  the  middle  phalanx.  Notice  the 
loose  mesh  and  the  small  amount  of  connective  tissue  between  the  tendon 
and  the  bone. 

These  sheaths  bear  almost  the  same  relation  to  the 
respective  fingers.  They  do  differ  slightly  in  their 
relation  to  the  palm  of  the  hand  as  pointed  out  in 
Chapter  VII.  The  proximal  end  of  the  sheath  for  the 
index  finger  is  in  relation  to  the  thenar  space,  while 
that  of  the  middle  finger  is  most  often  in  relation  to 
the  middle  palmar  space,  although  at  times  it  will 
allow  of  rupture  into  the  thenar  space,  possibly  through 
rupture  into  the  lumbrical  space  between  the  index 
and  middle  finger  and  thence  into  the  thenar  space. 
However,  this  lumbrical  space  itself  most  often  leads 
into  the  middle  palmar  space.  The  tendon  sheaths  of 
the  ring  finger  and  of  the  little  finger  are  in  relation 
to  the  middle  palmar  space. 


TENDON  SHEATH  OF  THE  FLEXOR  LONGUS  POLLICIS  105 

THE  RADIAL  BURSA  AND  THE  TENDON  SHEATH  OF  THE  FLEXOR  LONGUS 

POLLICIS. 

This  is  of  great  importance  from  a  surgical  stand- 
point, owing  to  the  fact  that  in  youth  and  adult  life 
the  sheath  nearly  always  communicates  with  the 
enlarged  sac  of  the  tendon  sheath  at  the  wrist  (19  in 
20  cases,  Poirier).  The  entire  sheath  has  been  given 
the  name  of  radial  bursa,  although  technically  speak- 
ing it  should  be  applied  only  to  the  proximal  part  at 
the  wrist. 

The  sheath  begins  distally  at  the  base  of  the  distal 
phalanx  and  extends  proximally  a  thumb's  breadth 
proximal  to  the  anterior  annular  ligament.  It  lies 
first  in  close  proximity  to  the  proximal  phalanx,  but 
at  the  distal  end  of  the  metacarpal  bone  becomes 
separated  from  the  bone  by  the  muscles  of  the  thumb 
lying  between  the  outer  head  of  the  flexor  brevis 
pollicis  and  the  adductor  obliquus  pollicis  (Figs.  24 
and  25).  At  times  (i  to  20,  Poirier)  there  is  a  separa- 
tion of  the  sheath  into  two  parts  about  the  middle 
of  the  metacarpal  bone.  This  is  frequently  only  a 
thin  diaphragm.  The  sheath  is  generally  well  sepa- 
rated by  connective  tissue  from  the  metacarpo- 
phalangeal  joint  and  an  infection  may  spread  from 
the  joint  to  the  sheath,  or  vice  versa,  but  either  is 
uncommon.  It  lies  superficial  to  the  proximal  end  of 
the  thenar  space,  in  juxtaposition  to  the  flexor  tendons 
in  the  carpal  canal  (Fig.  24)  and  passes  upward  to 
terminate  about  an  inch  above  the  annular  ligament 
by  a  rounded  cul-de-sac  extending  under  the  deep 
surface  of  the  tendon,  corresponding  to  the  radio- 
carpal  joint  and  the  lower  end  of  the  radius,  lying 
on  the  pronator  quadratus. 

The  communication  between  this  and  the  ulnar  bursa 
will  be  discussed  later.  The  motor  nerve  to  the  thenar 


106 


THE  TENDON  SHEATHS 


muscle  lies  within  a  finger's  breadth  distal  to  the 
annular  ligament  and  superficial  to  the  sheath  (see 
p.  no). 


THE  ULNAR  BURSA  AND  THE  SHEATH  OF  THE  TENDON  OF  THE  LITTLE 

FINGER. 

The  tendon  sheath  of  the  flexor  tendon  of  the  little 
finger  communicates  freely  with   the  ulnar  bursa  in 

FIG.  28 


X-ray  picture  upon  which  are  shown  two  types  seen  in  the  flexor  tendon 
sheaths.  Note  that  in  the  hand  upon  the  left  side  there  is  a  continuation 
between  the  little  finger  and  the  thumb  and  the  ulnar  bursa  and  radial  bursa 
respectively.  Note  also  the  connecting  sheaths  between.  In  the  hand 
upon  the  right  side  the  sheaths  are  separated,  not  alone  from  their  respec- 
tive fingers,  but  from  each  other. 


THE  ULNAR  BURS  A   AND  THE  LITTLE  FINGER     107 

about  one-half  of  the  cases  according  to  Poirier,  but 
statistics  vary  somewhat  on  this  point.  When  the 
separation  is  present  it  is  of  any  grade,  from  a  simple 
narrowing  to  a  complete  occlusion  some  millimeters  in 
length.  In  these  cases  the  sheath  corresponds  in  length 
to  those  of  the  other  fingers.  Also  the  relations  to  the 
joints  and  spaces  are  the  same  except  that  there  is 
no  lumbrical  canal  upon  the  ulnar  side  of  the  proximal 
end.  The  sheath  extends  into  the  middle  palmar 
space,  and  the  lumbrical  canal  upon  its  radial  side 

FIG.  29 


UB  S    S  FLP 

Showing  the  relation  of  the  tendons  and  synovial  sheaths  at  the  wrist. 
Note  in  this  drawing  the  four  pockets  in  the  ulnar  bursa  instead  of  three  as 
commonly  described;  also  the  tendon  sheath  of  the  flexor  longus  pollicis 
and  the  accessory  synovial  sheaths  (55).  See  text  for  description  of  the 
difference  between  the  relations  of  the  tendons  shown  in  Figs.  25  and  29. 

communicates  with  the  same  area.  In  this  relation 
it  should  be  remembered  that  these  muscles  do  not 
lead  into  the  thenar  and  middle  palmar  spaces  directly, 
but  lie  just  superficial  to  them,  in  a  loft,  as  it  were, 
from  which  pus  easily  extends  into  the  space. 

The  ulnar  bursa  proper  (Fig.  28)  begins  at  the 
proximal  end  of  the  finger  sheath,  spreads  out  rapidly, 
and  becomes  a  good-sized  sac  overlapping  the  meta- 
carpal  of  the  ring  finger  and  the  head  of  the  middle 
metacarpal,  passes  under  the  anterior  annular  ligament 
and  extends  a  thumb's  breadth  above  this,  lying  in 


108 


THE  TENDON  SHEATHS 


FIG.  30 


r 


relation  to  the  lower  end  of  the  ulna  and  the  ulnar 
side  of  the  carpus  and  the  radio-ulnar  articulation, 
lying  upon  the  pronator  quadratus.  It  does  not  sur- 
round the  tendons  as  a 
whole,  but  lies  to  the  ulnar 
side  of  the  group  of  super- 
ficial and  deep  flexors  and 
only  envelops  them  as  if 
they  were  pushed  in  along 
the  outside.  It  follows, 
then,  that  the  ulnar  side  of 
the  sac  is  free  while  the 
radial  side  envelops  the  ten- 
dons, forming  three  spaces 
or  arches,  as  it  were,  the 
most  superficial  between  the 
aponeurosis  and  the  super- 
ficial tendons,  the  middle 
between  the  superficial  and 
deep  tendons,  and  the  third 
between  the  deep  tendons 
and  the  carpal  canal  (Figs. 
25,  29,  and  30).  These  all 
open  upon  the  ulnar  side 
into  a  common  space.  This 
arrangement,  first  drawn 
attention  to  by  Leguey,  I 

Photograph     after     Poiner,     in 

which  the  ulnar  bursa  has  been  believe,  is  in  general  true, 
opened,  showing  its  extension  into  but  the  arrangement  varies 

the  little    finger   and    its    closure  *. rf  ,  ,     . 

about  the  tendon  of  the  ring  at  different  levels  and  in 
finger.  different  individuals,  as  can 

be  seen  by  examining  Fig. 

29,  where  there  are  four  pockets,  and  none  of  them 
very  deep.  Moreover,  the  tendons  upon  the  radial 
side  frequently  have  sheaths  separate  from  the  ulnar 
bursa,  as  will  be  mentioned  under  our  fourth  caption, 


THE   ULNAR  BURSA  AND  THE  LITTLE  FINGER     109 

"The  Intercommunication  of  the  Sheaths."  Attention 
should  also  be  drawn  to  the  fact  that  the  superficial 
palmar  arch  with  some  of  the  unimportant  branches 
of  the  ulnar  nerve  lies  superficial  to  the  sheath.  More 
important,  however,  is  the  fact  that  the  sheath  over- 
lies the  middle  palmar  space,  making  part  of  its  roof, 
as  it  were  (Fig.  31). 

FIG.  31 


Cross-section  No.  VI. — Through  distal  part  of  thenar  area.  A  TP,  ad- 
ductor transversus  pollicis;  DIA,  dorsalis  indicis  artery;  DP  A,  deep  palmar 
arch;  DSAS,  dorsal  subaponeurotic  space;  DSCS,  dorsal  subcutaneous  space; 
ECT,  extensor  communis  tendon;  FLP,  flexor  longus  pollicis  in  its  synovial 
sheath;  HM,  hypothenar  muscles  with  intermuscular  spaces;  ITS,  indefinite 
thenar  spaces;  IM,  interossei  muscles;  IS,  space  between  adductor  trans- 
versus and  first  dorsal  interosseous;  LM,  lumbrical  muscle;  M,  metacarpal 
bone;  MA  and  N,  median  artery  and  nerve;  MPS,  middle  palmar  space; 
PF,  palmar  fascia;  PIM,  palmar  interosseous  membrane;  TM,  thenar  muscles; 
TMF,  tendon  of  middle  finger;  TS,  thenar  space;  UV  and  N,  ulnar  vessels 
and  nerves.  The  ulnar  bursa,  radial  bursa,  and  an  intermediate  tendon 
sheath  are  shown  in  red.  The  boundaries  of  the  middle  palmar  and  thenar 
spaces  are  shown  in  blue. 

Above  the  anterior  annular  ligament  it  is  well  to 
note  that  the  tendons  of  the  palmaris  longus  and  the 
flexor  carpi  radialis  lie  above  the  radial  bursa,  and  that 
by  drawing  the  tendon  of  the  flexor  carpi  radialis  to 


110  THE  TENDON  SHEATHS 

the  radial  side  one  can  come  down  directly  upon  the 
flexor  longus  pollicis  and  its  sheath.  Attention  should 
likewise  be  drawn  to  the  fact  that  the  median  nerve 
lies  rather  deeply  between  the  two  bursae. 

THE  INTERCOMMUNICATION  OF  THE  SHEATHS. 

Poirier1  discusses  the  communication  between  the 
bursae  as  follows: 

"The  synovial  sheaths  of  the  palm  have  no  com- 
munication with  each  other,  and  the  authors  cite  in 
proof  of  this  the  case  of  Gosselin,  who  had  observed 
it  only  once.  However,  the  result  of  my  observation 
has  been  that  this  communication  between  the  two 
important  sheaths  is  very  frequent  in  the  adult.  It 
is  found  in  about  half  of  the  cases.  The  connection 
is  made  by  a  median  synovial  sheath  which  I  will 
describe. 

"Accessory  synovial  sacs:  The  writers  call  atten- 
tion to  the  occasional  existence  of  synovial  sheaths  in 
addition  to  the  two  large  synovial  sheaths,  which  they 
call  accessory  sheaths,  and  are  found  at  times  along 
the  flexor  tendons  of  the  index  finger.  They  lie  be- 
tween the  ulnar  and  radial  bursae,  being  found  especially 
along  the  deep  tendon.  My  researches  show  that  these 
synovial  sheaths  are  two  in  number.  They  ought  not 
to  be  called  accessory,  since  one  of  these  is  almost 
always  present.  I  have  named  them  the  intermediary 
anterior  and  posterior  palmar  synovial  sheaths. 

"The  intermediary  posterior  palmar  sheath:  This 
should  be  described  as  a  normal  sheath,  since  one  finds 
it  about  eight  times  out  of  ten.  It  lies  between  the 
carpal  canal  and  the  flexor  profundus  of  the  index 
finger,  and  commences  above  the  wrist  at  the  edge  of 
the  radius.  It  spreads  out  at  the  level  of  the  upper 

1  P.  Poirier  et  A.  Charpy,  Traite"  d 'Anatomic  Humaine,  Tome  ii.  S.  189. 


THE  INTERCOMMUNICATION  OF  THE  SHEATHS     111 

border  of  the  semilunar  bone  and  goes  down  more 
or  less  on  the  tendon  of  the  flexor  profundus,  varying 
from  3  to  8  cm.  To  see  it,  it  is  necessary  to  cut  trans- 
versely across  the  mass  of  muscles  and  tendons  in 
the  lower  third  of  the  forearm  and  turn  the  distal  end 
down  toward  the  fingers.  It  is  by  the  intervention  of 
this  sheath  that  the  ulnar  and  radial  bursae  communi- 
cate ordinarily. 

"The  anterior  intermediary  palmar  sheath:  This  is 
found  in  hardly  half  of  the  cases.  Much  smaller  than 
the  preceding,  it  is  found  placed  between  the  super- 
ficial and  deep  tendons  of  the  index  finger. 

"Both  of  these  appear  later  than  the  others,  and  it 
is  very  rare  to  find  them  as  completely  organized.  In 
general,  their  walls  lack  the  moist  glassiness  character- 
istic of  complete  development." 

It  is  said1  also  that  the  synovial  sheaths  of  the  ring, 
middle,  and  index  fingers  communicate  exceptionally 
with  the  ulnar  bursa,  following  their  respective  tendons, 
occurring  in  the  order  of  frequency  as  the  fingers  are 
named  above.  Again,  attention  should  be  drawn  to 
the  fact  that  the  intermediary  sheaths  may  differ 
from  that  type  mentioned  by  Poirier.  I  have  dissected 
one  case  in  which  the  profundus  tendons  of  the  index 
and  middle  fingers  had  separate  sheaths.  Communi- 
cating with  the  ulnar  bursa  (Fig.  25)  at  this  level  the 
anterior  intermediary  sheath  was  absent,  but  2  cm. 
higher  up  the  sheath  of  the  middle  finger  profundus  had 
disappeared,  while  the  anterior  and  posterior  interme- 
diary sheaths  were  present  (Fig.  29).  The  communi- 
cation here,  then,  would  have  taken  place  as  follows: 
Ulnar  bursa,  sheath  about  the  middle  finger  profundus, 
sheath  about  the  index  finger  profundus,  or  posterior 
intermediary  sheath,  and,  in  this  case  apparently, 

1  Tilleau,  Trait£  d  'Anatomie  Topographique. 


112  THE  TENDON  SHEATHS 

FIG.  32 


An  x-ray  picture  of  a  cadaver  hand  in  which  the  tendon  sheaths  have 
been  injected  with  red  lead.  The  outline  of  the  ulnar  bursa  and  radial  bursa 
with  tendon  prolongations  is  clearly  shown.  Note  the  distance  of  the  radial 
bursa  from  the  metacarpal  bone  of  the  thumb  and  the  relation  of  the  ulnar 
bursa  to  the  metacarpal  bone  of  the  middle  finger. 


THE  INTERCOMMUNICATION  OF  THE  SHEATHS     113 

anterior  intermediary  sheath,  to  the  radial  bursa.  It 
can  be  seen  that  in  a  fulminating  type  of  infection, 
such  as  a  streptococcus  involvement,  the  process  would 

FIG.  33 


Photograph  from  Bardeleben,  showing  tendons  upon  the  back  of  the  hand 
passing  under  the  posterior  annular  ligament. 

spread  to  the  radial  bursa,  but  in  the  more  chronic 
types  this  devious  course  offers  many  chances  for 
adhesive  occlusion  of  the  channel  (Fig.-  32).  This  will 
be  discussed  later  (see  p.  215). 


114  THE  TENDON  SHEATHS 

THE  SHEATHS  UPON  THE  DORSUM. 

The  synovial  sheaths  of  the  hand  upon  the  dorsum 
are  six  in  number.  These  begin  just  above  the  pos- 
terior annular  ligament  and  pass  under  and  through  it 
(Figs.  26  and  33).  They  are  found  as  follows: 

1.  Lying  upon  the  outer  side  of  the  styloid  process 
of  the  radius,  for  the  extensor  ossis  metacarpi  pollicis 
and    the   extensor   brevis   pollicis.      They   may    have 
separate  sheaths  and  are  5  to  6  cm.  in  length. 

2.  Behind  the  styloid  process,   for  the  tendons  of 
the  extensor  carpi  radialis  longior  and  brevior.    These 
are  5  to  6  cm.  in  length  and  communicate  with  the 
sheath  of  the  extensor  longus  pollicis  through  an  oval 
opening  by  way  of  the  longior   (Poirier). 

3.  Overlapping  the  above  tendons,  and  communica- 
ting with  them  as  described,  we  have  the  sheath  of  the 
extensor  longus  pollicis.    This  is  6  to  7  cm.  in  length. 

4.  To  the  ulnar  side  of  this  we  find  the  large  sheath 
enclosing  the  tendons  of  the  extensor  communis  digi- 
torum  and  the  extensor  indicis.     It  is  5  to  6  cm.  in 
length  and  terminates  below  in  three  prolongations. 
The  radial  one  encloses  the  communis  tendon  to  the 
index  finger  and  the  extensor  indicis;  the  middle,  the 
communis  tendon  to  the  middle  finger;  the  one  on  the 
ulnar  side  covers  the  tendons  to  the  third  and  fourth 
fingers. 

5.  One  opposite  the  interval  between  the  radius  and 
ulna,  for  the  extensor  minimi  digiti.     This  is  longer 
than  the  others,  being  6  to  7  cm.  in  length.    Covering 
the  upper  one-third  of  the  length  of  the  third  inter- 
osseous  space,  it  may  bifurcate  below,  following  the 
two  branches  of  the  tendon. 

6.  Upon  the  back  of  the  ulna,  the  synovial  sheath 
ofthe  tendon  of   the  extensor   carpi    ulnaris.    This  is 
4  to  5  cm.  in  length. 


CHAPTER   IX. 

THE    RELATION    BETWEEN   THE   SYNOVIAL 
SHEATHS  AND  THE  FASCIAL  SPACES. 

A  STUDY  BY  EXPERIMENTAL  INJECTION  OF  THE  OUT- 
LINES,   BOUNDARIES,   AND    DIVERTICULA   OF   THE 
FASCIAL  SPACES  AND  THE  RELATION  OF  THESE 
TO  THE  SYNOVIAL  SHEATHS. 

IN  my  desire  to  corroborate  the  findings  by  dissec- 
tion in  relation  to  the  fascial  spaces  and  tendon  sheaths 
which  have  been  detailed  in  the  two  preceding  chapters, 
a  large  number  of  hands  were  injected  after  the  manner 
described  in  Chapter  VII.  The  results  obtained  were 
most  satisfactory,  since  they  were  so  uniform  that  they 
absolutely  fixed  the  boundaries  and  relations  of  the 
spaces  and  sheaths.  Moreover,  these  experiments  gave 
results  which,  when  applied  clinically,  were  of  inesti- 
mable value  in  determining  the  course  the  infections 
tended  to  pursue.  Again,  they  determined  not  only 
the  proper  sites  for  opening  any  particular  focus,  but 
also  indicated  where  secondary  abscesses  would  be 
located,  and  thus  favored  early  diagnosis  and  treatment 
of  such  processes.  Furthermore,  they  demonstrated 
the  relation  between  tendon-sheath  abscesses  and 
fascial-space  abscesses.  These  studies  have  been  of 
greater  aid  than  any  other  in  placing  the  treatment 
of  infections  of  the  hand  upon  a  scientific  basis. 

A  brief  outline  of  the  various  procedures  will  be 
of  value  in  preserving  a  general  picture.  This  will  be 
followed  by  a  discussion  of  the  individual  experiments. 

Our  first  group  of  experiments  had  for  its  object  the 
determination  of  the  relation  of  rupture  of  the  synovial 


116     SYNOVIAL  SHEATHS  AND  FASCIAL  SPACES 

sheaths  to  the  secondary  abscesses  in  the  fascial  spaces. 
In  other  words,  if  an  infection  began  in  a  particular 
tendon  and  ruptured  from  it,  where  would  the  sec- 
ondary abscess  lie?  This  was  determined  by  an  exten- 
sive series  of  experiments  upon  each  sheath.  Clinical 
evidence  has  accumulated  in  my  hands  sufficient  to 
verify  every  one  of  the  experimental  deductions  we 
have  here  made. 

The  second  problem  dealt  with  determining  the 
boundaries  and  diverticula  of  each  of  the  definite 
spaces  I  have  described.  To  do  this  injections  of  these 
spaces  were  made  from  every  possible  source  of  infec- 
tion— the  tendon  sheaths,  direct  implantation,  and 
extension  from  neighboring  spaces.  The  results  were 
uniform,  as  will  be  seen  by  a  study  of  the  experi- 
ments. 

Again,  certain  of  these  injections  were  made  with 
great  force  to  determine  where  pus  would  extend  when 
it  ruptured  from  these  individual  spaces. 

Therefore,  by  these  experiments  we  have  determined 
for  the  synovial  sheaths,  the  sites  of  extension;  and 
for  each  fascial  space,  (a)  the  source  of  involvement; 
(b)  the  normal  limitations  of  that  space;  (c)  the  areas 
to  which  pus  will  extend  from  the  space.  Here  again 
clinical  evidence  will  be  later  adduced  to  show  that  all 
of  these  deductions  are  pathologically  correct. 

For  the  sake  of  clearness  a  tabulation  of  these 
experiments  is  appended. 

I.  The  relation  of  rupture  of  the  tendon  sheaths 
to  the  fascial  spaces. 

From  the  tendon  sheath  of  the  middle  finger,  Experi- 
ments i  and  2. 

From  the  tendon  sheath  of  the  ring  finger,  Experi- 
ments 3,  4,  18,  19,  and  20. 

.From  the  tendon  sheath  of  the  little  finger,  Experi- 
ments 5,  6,  7,  and  47. 


OUTLINES  AND  DIVERTICULA  OF  FASCIAL  SPACES     117 

From  the  tendon  sheath  of  the  index  finger,  Experi- 
ments 8,  9,  27,  and  35. 

From  the  tendon  sheath  of  the  thumb,  Experiments 
10  to  17. 

II.  The  boundaries  and  diverticula  of  the  spaces. 

(a)  Middle  palmar  space. 

Injection  via  ring  finger  sheath,  Experiments  3,  4, 
1 8  to  20. 

Injection  via  little  finger  sheath,  Experiments  I 
and  2. 

Injection  via  little  finger  sheath,  Experiments  5,  6, 
7,  and  47. 

Injection  via  palmar  fascia,  Experiments  21  to  25. 

Injection  via  lumbrical  muscle  space,  Experiments 
26  A  and  26  B. 

Of  these,  great  force  was  used  in  19,  20,  and  3. 
From  these  and  others,  deductions  were  made  as  to 
the  location  of  pus  extensions  from  the  middle  palmar 
space. 

(b)  Thenar  space. 

Injection  via  index  finger  sheath,  Experiments  27 
to  35,  8  and  9. 

Injection  via  palmar  fascia,  Experiments  36,  37, 
and  38. 

Of  these,  great  force  was  used  in  the  experiments 
from  27  to  35  inclusive,  and  from  the  results  deduc- 
tions were  made  as  to  the  location  of  pus  extensions 
from  the  thenar  space. 

(c)  Dorsal  subcutaneous  space. 

Injection  between  first  and  second  metacarpals, 
Experiments  39  and  40. 

Injection  between  second  and  third  metacarpals, 
Experiments  41  and  42. 

(d)  Dorsal  subaponeurotic  space. 
Experiments  43,  44,  and  45. 

(e)  Hypothenar  space. 


118 

General  results  of  experiments  quoted. 

(/)  Forearm  space. 

Injection  via  flexor  longus  pollicis  sheath,  Experi- 
ments 46,  10  to  17. 

Injection  via  ulnar  bursa  and  little  finger,  Experi- 
ments 47  and  50. 

Injection  via  middle  palmar  space,  Experiment  49. 

Injection  along  radial  and  ulnar  vessels,  grouped 
under  composite  experiment  51. 


THE  RELATION  OF  THE  TENDON-SHEATH  RUPTURE  TO  THE 
FASCIAL  SPACES. 

INJECTION  VIA  THE  TENDON  SHEATH  OF  THE  MIDDLE  FINGER. 

In  inserting  the  cannula  no  effort  was  made  to  reach 
any  particular  spot,   but  it  was  allowed   to  rupture 

FIG.  34 


Schematic  drawing  made  from  a  dissection  of  a  hand  injected  from  the 
tendon  sheath  of  the  middle  finger.  The  mass  filled  the  middle  palmar  space 
and  extended  along  the  two  lumbricals. 


INJECTION  VIA  TENDON  SHEATH  OF  RING  FINGER     119 

through  the  weakest  spot  in  its  course.  It  will  be 
noted  that  in  each  instance  the  mass  entered  and  filled 
the  middle  palmar  space. 

Experiment  i. — Left  hand.  Cannula  inserted  into 
tendon  sheath  of  middle  finger  at  the  middle  of  the 
proximal  phalanx,  moderate  force  used  in  injection. 
The  mass  occupied  the  middle  palmar  space  only,  going 
up  to  about  one-half  inch  below  the  annular  ligament. 
Downward  it  had  returned  along  the  lumbrical  muscles 
of  the  little  and  ring  fingers  nearly  to  the  web  of  the 
fingers.  It  did  not  return  to  any  extent  along  the 
lumbrical  muscles  of  the  middle  finger.  In  every  way 
this  was  a  perfect  representation  of  what  is  probably 
a  typical  collection  in  the  middle  palmar  space.  (See 
experimental  injection  drawing,  Fig.  34.) 

Experiment  2. — Left  hand.  Same  as  No.  I  in  every 
particular.  No  mass  to  radial  side  of  middle  finger. 

Experiment  2A. — Right  hand.  Same  as  No.  I  in 
every  particular. 

INJECTION  VIA  THE  TENDON  SHEATH  OF  THE  RING  FINGER. 

The  tendon  sheath  was  opened  at  the  base  of  the 
finger  and  the  cannula  inserted  in  the  sheath  and  pushed 
through  the  proximal  blind  end  into  whatever  space 
was  at  that  site,  thus  trying  to  demonstrate  where  an 
infection  would  spread  to  if  it  extended  from  the 
tendon  sheath.  In  one  case,  which  is  not  included  in 
the  report,  the  tendon  sheath  did  not  end  blindly, 
but  extended  up  into  the  group  of  tendons  at  the 
wrist.  In  every  case  where  the  sheath  ended  normally 
the  mass  filled  the  middle  palmar  space. 

Experiment  3.— Right  hand.  Moderate  force  used. 
In  this  case  the  mass  occupied  the  middle  palmar 
space  as  it  has  been  described.  No  diverticula 
were  noted  except  that  the  mass  extended  along  the 


120      SYNOVIAL  SHEATHS  AND  FASCIAL  SPACES 

lumbrical  muscles  of  the  ring  finger  for  about  one-half 
inch.     (See  experimental  injection  drawing,  Fig.  35.) 

Experiment  4. — Right  hand.  Moderate  force  used. 
In  this  case  the  cannula  broke  from  the  blind  end, 
evidently  superficial  to  the  tendon,  for  there  was  a 
small  mass  only,  lying  superficial  to  the  tendon,  about 
a  quarter  of  an  inch  wide  and  three-quarters  of  an  inch 
long.  It  had  not  involved  the  middle  palmar  space, 
but  it  was  seen  that  the  thinnest  wall  was  in  relation 
to  that  space,  and  in  case  of  infection  the  pus  would 
have  extended  into  it  in  all  probability.  (See  experi- 
mental injection  drawing,  Fig.  36.)  This  is  further 
supported  by  Experiments  18,  19,  and  20  (q.  v.). 

INJECTION  VIA  THE  TENDON  SHEATH  OF  THE  LITTLE  FINGER. 

The  injections  5  and  6  demonstrate  where  the  pus 
will  lie  in  those  cases  in  which  the  rupture  takes  place 
in  the  hand,  namely,  the  middle  palmar  space.  It 
may  also  rupture  in  the  forearm.  In  fact,  that  is  its 
most  frequent  site.  The  location  of  the  pus  in  the 
latter  case  will  be  seen  by  studying  Experiment  47. 

Experiment  5. — During  an  attempt  to  inject  the 
ulnar  sheath  in  the  right  hand  it  was  found  to  be 
obliterated  at  the  phalangometacarpal  articulation. 
The  cannula  broke  out  into  a  space  which  was  injected 
with  moderate  force,  and  upon  dissection  the  middle 
palmar  space,  as  already  described,  was  found  filled 
with  the  mass.  It  had  not  gone  up  into  the  wrist,  over 
into  the  thenar  or  hypothenar  areas,  but  had  returned 
along  the  lumbrical  muscles  of  the  little,  ring,  and 
middle  fingers.  (See  experimental  injection  drawing, 

Fig.  37-) 

Experiment  6. — In  another  attempt  to  inject  the 
ulnar  bursa  with  moderate  force,  the  injection  was 
arrested  at  the  annular  ligament  owing  to  the  rigidity 
of  the  tissue  of  the  subject.  Due  to  this  fact  and  the 


INJECTION  VIA  TENDON  SHEA  TH  OF  LITTLE  FINGER   ]  21 

FIG.  35 


Schematic  drawing  made  from  a  dissection  of  a  hand  injected  along  the 
tendon  sheath  of  the  ring  finger.  The  mass  filled  the  middle  palmar  space, 
with  extension  along  the  lumbrical  muscle. 

FIG.  36 


Schematic  drawing  made  from  a  dissection  of  a  hand  in  which  the  mass 
was  injected  from  the  tendon  sheath  of  the  middle  finger  and  filled  the  loft 
over  the  middle  palmar  space,  but  did  not  rupture  into  it. 


122     SYNOVIAL  SHEATHS  AND  FASCIAL  SPACES 

friability  of  the  tissues  incident  to  age,  the  ulnar  bursa 
ruptured  at  about  the  middle  of  the  palm,  and  the  mass 
was  found  to  occupy  the  middle  palmar  space  only, 
in  addition  to  the  ulnar  bursa  sheath  of  the  tendons. 
The  mass  returned  along  the  ring  finger  lumbrical 
only.  The  surgical  importance  of  this  experiment  is 
readily  seen.  (See  experimental  injection  drawing, 

Fig.  38). 

Experiment  7. — Here  we  have  the  result  produced 
in  those  cases  in  which  the  rupture  is  in  the  forearm 
and  not  in  the  hand.  The  x-ray  photograph  here  pre- 
sented, which  is  made  from  the  hand  injected  in  Experi- 
ment 7,  presents  a  clear  picture  of  the  bones  in  their 
relation  to  the  injected  bloodvessels  and  ulnar  bursa 
(Fig.  39).  Upon  this  plate  have  been  placed  lines 
which  represent  the  boundaries  of  the  thenar  and 
middle  palmar  spaces.  The  numerous  parallel  lines 
at  the  distal  end  of  the  palm  represent  the  dense 
tissue  here  overlying  the  articulation,  in  which  there 
are  no  spaces  except  those  made  by  the  lumbrical 
muscles  with  the  vessels  and  the  synovial  sheaths. 
(See  cross-section,  Fig.  22.)  Three  curved  lines  show 
the  position  of  the  flexion  creases  of  the  palm  of  the 
hand,  and  in  relation  to  these,  note  that  the  proximal 
end  of  the  distal  flexion  crease  corresponds  with  the 
beginning  of  the  dense  tissue  noted.  Again,  note  that 
the  distal  end  of  the  middle  flexion  crease  also  begins 
at  the  dense  tissue,  and  hence  a  line  drawn  between 
these  two  points  limits  the  palmar  spaces  distally. 
Pay  particular  attention  to  the  point  at  which  this 
middle  flexion  crease  crosses  the  space  between  the 
metacarpal  bones  of  the  middle  and  ring  fingers,  at 
the  distal  end  of  the  middle  palmar  space,  avoiding  the 
thenar  space  upon  the  radial  side,  the  ulnar  bursa 
upon  the  ulnar  side,  the  dense  tissue  distally,  and  the 
deep  palmar  arch  which  is  seen  crossing  the  upper 


INJECTION  VIA  TENDON  SHEA  TH  OF  LITTLE  FINGER   123 

FIG.  37 


Schematic  drawing  made  from  a  dissection  of  a  hand  injected  from  the 
tendon  sheath  of  the  little  finger  with  which  the  ulnar  bursa  did  not  connect. 
The  mass  ruptured  into  the  middle  palmar  space,  filling  it  with  prolonga- 
tions along  three  lumbrical  muscles. 

'  FIG.  38 


Schematic  drawing  made  from  a  dissection  of  a  hand  in  which  the  mass 
was  injected  along  the  tendon  sheath  of  the  little  finger;  closure  at  the  upper 
end  of  the  annular  ligament  of  the  ulnar  bursa  allowed  rupture  from  the 
ulnar  bursa,  the  mass  filling  the  middle  palmar  space,  with  extension  along 
one  lumbrical  muscle. 


124    \SYNOVIAL  SHEATHS  AND  FASCIAL  SPACES 

part  of  the  middle   palmar  space  proximally.     Note 
that  although  the  injection  mass  has  broken  from  the 

FIG.  39 


-X"-ray  Plate.  Boundaries  of  the  thenar  (TS)  and  middle  palmar  spaces 
(MPS)  marked  and  proper  site  for  opening  the  latter  indicated.  Ulnar 
bursa  and  bloodvessels  injected. 


ulnar  sheath  in  the  forearm,  yet  the  spaces  in  the  hand 
are  uninvolved. 


INJECTION  VIA  TENDON  SHEA  TH  OF  INDEX  FINGER     1 25 

Experiments  54  to  58. — In  these  as  with  many  other 
experiments,  the  records  of  which  are  not  here  re- 
ported, the  mass  ruptured  at  the  proximal  end  of  the 
sheath  under  the  flexor  profundus  tendons  in  the 
forearm.  This  is  the  most  common  site  of  extension. 
(See  Experiment  50  for  a  complete  description  of  these 
cases.) 


INJECTION  VIA  THE  TENDON  SHEATH  OF  THE  INDEX  FINGER. 

Here  the  findings  are  positive.     In  addition  to  the 
experiment  here  detailed,  many  others  were  performed 

FIG.  40 


Schematic  drawing  made  from  a  dissection  of  a  hand  injected  along  the 
tendon  sheath  of  the  index  finger.  Mass  filled  thenar  space  and  extended 
around  to  the  dorsum  underneath  adductor  transversus  and  also  along  lum- 
brical  muscle. 

which   gave   the  definite  information   that  when   pus 
ruptures  from  this  sheath  it  enters  the  thenar  space. 


126     SYNOVIAL  SHEATHS  AND  FASCIAL  SPACES 

Experiment  8. — Injection  was  made  through  the 
tendon  sheath  of  the  index  finger.  The  mass  occupied 
the  thenar  space;  did  not  go  into  the  forearm  or  middle 
palmar  space.  Passed  around  the  lower  or  distal  edge 
of  the  adductor  transversus,  filled  a  space  the  size  of 
a  walnut  between  that  muscle  and  the  first  dorsal 
interosseous,  and  abutted  on  the  dorsal  subcutaneous 
tissue  at  web.  Followed  index  lumbrical  only.  (See 
experimental  injection  drawing,  Fig.  40.) 

Experiment  9. — Same  findings  as  in  Experiment  8. 

Experiments  24  to  30  and  29  to  35  corroborate  these 
findings. 

INJECTION  VIA  THE  TENDON  SHEATH  OF  THE  FLEXOR  LONGUS 
POLLICIS. 

Here  one  would  expect  the  mass  to  enter  the  thenar 
space  in  the  hand,  and  we  were  therefore  surprised  to 
find  that  this  was  not  generally  the  case.  To  deter- 
mine this  point  definitely,  eight  experiments  were  made. 
In  each  case  great  pressure  was  used  in  the  injection. 
The  cannula  was  inserted  into  the  tendon  sheath  in  the 
thumb  and  so  bound  that  the  mass  could  not  escape 
around  the  needle.  These  experiments  showed  that 
in  a  majority  of  cases  the  rupture  took  place  in  the 
forearm  under  the  flexor  profundus  digitorum.  It  did  at 
times,  however,  rupture  distal  to  the  annular  ligament 
and  fill  the  thenar  and  even  the  middle  palmar  spaces. 

Experiment  10. — A  cannula  was  inserted  into  the 
sheath  of  the  flexor  longus  pollicis  at  the  thumb.  The 
injection  mass  was  found  to  have  filled  completely  the 
radial  bursa,  including  the  part  proximal  to  the  annular 
ligament.  The  mass  had  ruptured  from  the  proximal 
end  and  passed  up  into  the  forearm.  No  extravasation 
had  taken  place  into  the  hand,  either  by  direct  rupture 
or  retrograde  extension.  The  attachment  of  the  flexor 
longus  pollicis  at  its  origin  had  been  torn  in  part  from 


TENDON  SHEATHS  AND  FASCIAL  SPACES       127 

the  bone.  The  mass  extended  up  along  this  muscle 
on  the  radial  side  of  the  forearm,  having  on  its  ulnar 
boundary  and  roof  the  flexor  profundus  digitorum  and 
the  flexor  sublimis  digitorum.  The  major  portion  of 
the  mass  was  found  under  the  flexor  profundus  digi- 
torum, going  over  even  to  the  flexor  carpi  ulnaris.  It 
filled  an  area  extending  from  the  wrist-joint  to  within 
three  inches  of  the  elbow-joint. 

Experiment  n. — The  findings  here  were  practically 
the  same  except  that  a  small  part  of  the  mass  passed 
downward  under  the  annular  ligament  and  the  ulnar 
bursa  to  fill  partially  the  middle  palmar  space.  This, 
however,  would  probably  not  occur  in  an  inflam- 
matory case  owing  to  the  small  channel  present. 

Experiment  12. — In  this  case  the  mass  ruptured 
from  the  upper  third  of  the  synovial  sheath,  just 
distal  to  the  annular  ligament.  It  extended  downward 
to  the  thenar  space  and  partially  filled  it.  A  small 
part  had  also  entered  the  upper  end  of  the  palmar 
space,  owing  to  the  indefinite  septum  separating  these 
spaces  at  the  upper  end.  The  large  mass,  however, 
was  in  the  thenar  space,  but  it  demonstrated  that 
extension  into  the  middle  palmar  space  would  be  pos- 
sible in  neglected  cases. 

Experiments  13,  14,  15,  and  16. — These  were  prac- 
tically duplicates  of  the  above  results. 

Experiment  17. — In  this  case  there  was  apparently 
a  free  anatomical  communication  between  the  ulnar 
and  radial  bursa,  for  the  mass  filled  the  ulnar  bursa. 
There  was  also  an  extension  into  the  forearm  from  a 
rupture  of  the  proximal  end  at  the  radial  bursa. 

GENERAL  DEDUCTIONS  AS  TO  RELATION  OF  TENDON  SHEATHS  TO 
FASCIAL  SPACES. 

The  injections  through  the  synovial  sheaths  of  the 
tendons  of  the  ring  and  middle  fingers  passed  into  the 


128     SYNOVIAL  SHEATHS  AND  FASCIAL  SPACES 

middle  palmar  space,  while  that  space  was  reached 
also  from  the  little  finger  in  those  cases  where  the 
synovial  sheath  was  distinct  from  the  ulnar  bursa; 
and,  indeed,  the  contents  of  the  ulnar  bursa  itself, 
when  it  ruptured  into  the  palm,  entered  the  same 
space.  Injection  masses  from  the  index  synovial  sheath 
passed  into  the  thenar  space.  In  those  cases  where  the 
synovial  sheath  of  either  of  these  fingers  communi- 
cated with  the  ulnar  bursa,  the  mass  passed  into  that, 
and  followed  the  course  of  any  bursal  injection.  The 
extreme  rarity  of  communication  between  the  index 
synovial  sheath  and  the  ulnar  bursa  robs  that  point 
of  any  surgical  interest  such  an  anomaly  would  have. 
A  mass  from  the  radial  bursa  or  the  synovial  sheath 
of  the  flexor  longus  pollicis,  if  it  ruptures  into  the  hand, 
will  lie  in  the  indefinite  spaces  mentioned  as  lying 
directly  over  the  muscles  of  the  metacarpal  bone  of 
the  thumb.  It  is  possible  for  it  to  erode  into  the  thenar 
space,  but  it  is  more  likely  to  rupture  into  the  fascial 
spaces  of  the  forearm  and  lie  under  the  flexor  profundus 
digitorum.  The  ulnar  bursa  may  rupture  into  the 
middle  palmar  space  and  it  will  almost  surely  rupture 
into  the  forearm  under  the  flexor  profundus  digitorum. 

THE    NORMAL   BOUNDARIES   OF   THE   FASCIAL    SPACES   AND 

THE    POSITION    OF   SECONDARY   ABSCESSES   IN    CASE    OF 

EXTENSION  FROM  THE  SPACES. 

THE  MIDDLE  PALMAR  SPACE. 

INJECTION  VIA  THE  TENDON  SHEATH  OF  THE  RING 
FINGER. — Experiment  18. — Left  hand,  along  tendon 
sheath  of  ring  finger;  the  mass  was  injected  with  con- 
siderable force.  The  middle  palmar  space  as  described 
was  filled.  Thenar  and  hypothenar  area  free,  mass 
followed  along  little  and  ring  finger  lumbricals  for  three- 
fourths  inch,  none  along  other  fingers,  none  through 
between  bones  to  back,  mass  extended  under  tendons 


THE  MIDDLE  PALMAR  SPACE  129 

strictly,  up  into  forearm,  where  a  large  mass  was 
found  lying  under  the  deep  muscles  upon  the  pronator 
quadratus  and  the  interosseous  septum  up  to  the 
pronator  radii  teres.  The  mass  came  to  the  surface 
late  upon  the  radial  side,  about  two  inches  above  the 
wrist,  but  the  mass  was  most  marked  upon  the  ulnar 
side  from  above  downward,  between  the  flexor  carpi 
ulnaris  and  the  deep  tendons  and  muscles.  The  im- 
portance of  the  position  of  this  mass  from  a  clinical 
standpoint  can  be  seen. 

Experiment  19.— Same  findings  as  in  Experiment  18. 

Experiment  20.— Wrist  bound  tightly  above  annular 
ligament;  cannula  inserted  along  ring  finger  synovial 
sheath,  and  mass  injected  with  great  force,  the  idea 
being  to  see  where  the  mass  would  rupture  in  case 
that  means  of  exit  was  closed.  None  of  the  mass  went 
to  the  forearm  or  .dorsum,  but  did  rupture  into  the 
thenar  space  at  the  upper  or  proximal  end  of  the 
intervening  septum  and  filled  the  thenar  space,  passed 
along  all  lumbrical  muscles  into  canals  for  a  consider- 
able distance,  but  not  out  into  the  web  between  the 
fingers.  (See  experimental  injection  drawing,  Fig.  41.) 

Experiments  3  and  4  corroborate  these  findings. 

Experiments  I,  2,  and  3,  in  which  the  space  was  in- 
jected from  the  middle  finger,  and  Experiments  5  and 
6,  in  which  the  space  was  injected  from  the  little 
finger,  present  the  same  findings  as  in  Experiments 
18,  19,  and  20. 

INJECTION  THROUGH  THE  PALMAR  FASCIA. — Injec- 
tion of  the  space  by  inserting  a  needle  through  the  palm 
directly  into  the  space  gives  the  results  uncomplicated 
by  any  other  process. 

Experiment  21. — Left  hand.  Cannula  inserted 
through  the  palmar  fascia  where  middle  flexion  crease 
crosses  metacarpal  space  between  ring  and  middle 
fingers.  Moderate  force  used. 

9 


130      SYNOVIAL  SHEATHS  AND  FASCIAL  SPACES 

NOTE. — Care  must  be  taken  that  the  cannula  goes 
dorsal  to  the  tendons,  i.  e.,  really  into  space,  otherwise 
the  mass  will  be  confined  to  the  imperfect  spaces 
around  the  tendons,  particularly  superficial  to  them. 
Even  if  this  should  occur,  if  great  force  is  used,  it  will 
rupture  into  the  great  space;  not  so  readily,  however, 
as  would  pus,  since  the  erosive  action  of  the  latter  is 
not  present  in  simple  injections. 

FIG.  41 


Schematic  drawing  made  from  a  dissection  of  a  hand  in  which  the  injec- 
tion was  made  along  the  tendon  sheath  of  the  ring  finger  under  great  force. 
The  mass  filled  the  middle  palmar  and  thenar  spaces,  with  extension  along 
all  lumbrical  muscles. 

Upon  dissection  the  mass  was  found  to  be  limited 
to  what  we  have  found  in  the  middle  palmar  space. 
It  was  limited  upon  the  radial  side  by  the  attachment 
of  fascia  to  the  middle  metacarpal  bone.  This  was  the 
long  leg  of  the  right-angle  triangle.  The  ulnar  side 
represented  the  hypotenuse  of  the  triangle  lying  to 


THE  MIDDLE  PALMAR  SPACE  131 

the  radial  side  of  the  hypothenar  space.  The  apex  of 
the  triangle,  or  the  highest  point  to  which  the  mass 
spread,  was  about  one  inch  distal  to  the  distal  flexion 
crease  of  the  wrist,  or  about  a  finger's  breadth  proximal 
to  a  line  drawn  transversely  across  the  palm  from  the 
web  of  the  extended  thumb. 

At  the  lower  part  of  the  palm,  i.  e.,  toward  the  web 
of  the  fingers,  the  greater  part  of  the  mass  was  limited 
by  a  line  drawn  between  the  radial  end  of  the  middle 
flexion  crease  and  the  ulnar  end  of  the  distal  flexion 
crease  of  the  palm,  or,  roughly  speaking,  about  a 
thumb's  breadth  above  the  web  of  the  fingers;  this  is 
the  short  leg  of  our  right-angle  triangle.  A  prolonga- 
tion of  the  mass  had  taken  place,  however,  along  the 
lumbrical  muscle  between  the  middle  and  ring  fingers, 
going  almost  to  the  web  of  the  fingers.  There  was  no 
appreciable  mass  along  the  other  lumbrical  muscles, 
although  some  of  the  stain  from  the  methylene  blue 
used  in  the  injection  mass  had  stained  the  space 
around  the  muscle  leading  to  the  little  finger.  No 
other  prolongations  were  present.  It  did  not  break 
into  the  interossei  muscles  or  superficially  about  the 
tendons.  Superficial  palmar  vessels  crossed  upper  part 
of  mass.  (See  experimental  injection  drawing,  Fig.  42.) 

Experiment  22. — Left  hand.  Injection  at  the  same 
point  and  in  the  same  manner  as  No.  21.  The  mass 
here  occupied  exactly  the  same  area  of  distribution 
as  in  Experiment  21,  except  the  mass  as  a  whole  was 
not  so  large,  being  a  little  larger  than  an  almond.  The 
most  prominent  part  of  the  mass  was  in  the  middle 
of  the  palm,  over  the  middle  metacarpal  space.  There 
were  slight  prolongations  distally  along  the  lumbrical 
muscle  between  ring  and  middle  metacarpals  as  above. 

Experiment  23. — Injection  made  same  as  in  Experi- 
ment 21.  Both  .T-ray  picture  and  dissection  made  of 
this  right  hand.  Mass  extended  somewhat  higher  in 


132     SYNOVIAL  SHEATHS  AND  FASCIAL  SPACES 

the  hand  than  in  Experiment  21,  going  to  a  point  about 
a  finger's  breadth  below,  i.  e.,  distal  to  the  distal 
flexion  crease  of  the  wrist  lying  dorsal  to  the  tendon 
group;  laterally  its  boundaries  were  the  same,  while 
at  the  distal  portion  of  the  palm  a  prolongation  of  the 
mass  occurred  along  the  lumbrical  muscles  going  to  the 

FIG.  42 


Schematic  drawing  made  from  a  dissection  of  a  hand  in  which  the  injec- 
tion was  made  through  the  palmar  fascia  into  the  middle  palmar  space. 
The  mass  filled  middle  palmar  space,  with  extension  along  one  lumbrical 
muscle. 

little,  ring,  and  middle  fingers.  This  is  of  considerable 
importance,  since  it  is  remembered  that  the  relation 
.of  the  lumbrical  muscle  of  the  middle  finger  to  the 
middle  palmar  space  was  discussed  in  the  division 
devoted  to  cross-sections,  and  this  experiment  bears 
out  the  assumption  hazarded  there  that  this  muscle 
space  was  really  a  diverticulum  of  the  middle  palmar 
space  and  not  of  the  thenar  space.  (See  cross-sections, 
Figs.  23  and  24.) 


THE  MIDDLE  PALMAR  SPACE 


133 


Experiment  24. — Injection  left  hand,  same  as  in 
Experiment  21.  Mass  occupied  same  space  as  in 
Experiment  21,  except  that  mass  spread  down  along 
lumbrical  muscle  of  little  and  ring  fingers  for  a  distance 
of  one-third  inch. 

FIG.  43 


X-ray  plate  made  from  a  hand  in  which  the  middle  palmar  space  was 
injected  with  a  mixture  of  red  lead  and  plaster  of  Paris.  Photograph  repre- 
sents location  of  pus  in  typical  middle  palmar  space  infection. 

INJECTION  THROUGH  PALMAR  FASCIA  INTO  MIDDLE 
PALMAR  SPACE. — Experiment  25  (see  x-ray  photograph, 
Fig.  43). — This  hand  was  also  dissected.  It  represents 
how  the  mass  extends  down  along  the  lumbrical 
muscles,  and  shows  also  what  site  should  be  opened 
to  evacuate  the  contents  of  the  space.  Note  that  the 
hypothenar  and  thenar  regions  are  uninvolved,  the 
mass  not  extending  to  the  radial  side  of  the  middle 
metacarpal.  It  is  seen  that  the  ulnar  bursa  would 
lie  over  the  ulnar  side  of  the  mass. 


134     SYNOVIAL  SHEATHS  AND  FASCIAL  SPACES 

INJECTION  ALONG  LUMBRICAL  MUSCLE  OF  RING 
FINGER. — Experiment  26A. — Cannula  inserted  along 
lumbrical  muscle,  left  hand.  Some  difficulty  was 
experienced  in  the  insertion,  but  when  successful  the 
mass  occupied  the  middle  palmar  space.  There  was 
no  return  along  the  lumbrical  muscles.  Moderate 
force  used  in  injection.  (See  experimental  injection 
drawing  Fig.  44.) 

FIG.  44 


Schematic  drawing  made  from  a  dissection  of  a  hand  in  which  the  injec- 
tion was  made  along  the  lumbrical  muscle  space  between  middle  and  ring 
fingers.  Middle  palmar  space  filled. 

Experiment  26B. — Right  hand.  Same  technique, 
injection  mass  lies  along  lumbrical  muscle.  Middle 
palmar  space  only  partly  filled. 

THE  THENAR  SPACE. 

NOTE. — The  first  injections'  of  this  space  were  very 
unsatisfactory,  owing  to  two  errors  in  technique,  which 
were  corrected  later.  In  the  first  place,  the  injections 


TENDON  SHEATH  OF  THE  INDEX  FINGER       135 

were  not  made  deep  enough;  and  secondly,  they  were 
too  far  to  the  radial  side  over  the  thumb.  It  is  true 
that  the  results  obtained  by  these  injections  were 
instructive  in  that  they  served  to  show  indefinite 
limited  spaces  at  these  sites,  but  they  did  not  reach 
the  large  space  under  consideration. 

FIG.  45 


Schematic  drawing  made  from  a  dissection  of  a  hand  in  which  the  injec- 
tion was  made  along  the  tendon  sheath  of  the  index  finger.  Mass  filled 
thenar  space  and  extended  to  dorsum  between  adductor  transversus  and 
adductor  obliquus. 

INJECTION  VIA  THE  TENDON  SHEATH  OF  THE  INDEX 
FINGER. — Experiment  27. — Right  hand.  Cannula  in- 
serted into  tendon  sheath  about  middle  of  proximal 
phalanx  and  ruptured  from  sheath  at  its  proximal  end. 
Moderate  force  used  in  injection.  The  mass  when 
dissected  out  showed  the  limitations  of  the  thenar  space 
as  described.  The  mass  passed  up  dorsal  to  the  tendon, 
to  a  thumb's  breadth  below  the  annular  ligament.  It 


136      SYNOVIAL  SHEATHS  AND  FASCIAL  SPACES 

did  not  go  to  the  ulnar  side  of  the  middle  metacarpal. 
The  mass  laid  directly  upon  the  adductor  transversus. 
It  did  not  go  along  the  lumbrical  muscle  to  the  side 
of  the  index  finger.  It  did  not  spread  around  under 
the  web  of  the  thumb  to  the  dorsum  of  the  hand,  but 
was  limited  at  the  distal  border  of  the  adductor  trans- 
versus. It  did  spread  to  the  back,  however,  at  the 
upper  or  proximal  edge  of  the  adductor  transversus, 
going  between  the  adductor  transversus  and  the  adduc- 
tor obliquus,  thus  lying  between  the  adductor  trans- 
versus and  the  first  dorsal  interosseous,  at  the  distal 
edge  of  which  it  came  to  lie  in  the  subcutaneous  tissue 
of  the  dorsum.  (See  experimental  injection  drawing, 

Fig.  45-) 

Experiment  28. — Injection  same  as  Experiment  27. 
Here  the  mass  did  not  fill  the  space  completely,  but  did 
return  along  the  lumbrical  muscle  to  the  radial  side 
of  the  index  finger;  condition  well  marked.  For  clinical 
purposes,  Experiments  27  and  28  should  be  studied 
together.  The  probability  is  that  the  cannula  did  not 
rupture  entirely  into  the  space,  but  did  get  out  of  the 
synovial  sheath  into  the  indefinite  spaces  in  the  loose 
connective  tissue  about  the  tendon  in  the  loft,  as  it 
were,  of  the  thenar  space.  (See  experimental  injection 
drawing,  Fig.  46.) 

INJECTION  OF  THE  THENAR  SPACE  UNDER  FORCIBLE 
PRESSURE. — The  index  synovial  sheath  was  opened 
and  cannula  forced  out  of  the  proximal  end  into  the 
palm;  forcible  pressure  with  force  pump  was  main- 
tained for  from  three  to  five  minutes.  Owing  to  the 
fact  that  the  routes  of  extension  from  the  thenar  space 
were  somewhat  difficult  to  determine  accurately,  nine 
injections  of  the  space  were  made,  with  the  following 
results.  In  none  of  the  cases  did  the  mass  go  up  into 
the  forearm.  In  3  cases  only  did  it  go  into  the  middle 
palmar  space.  In  8  cases  the  mass  passed  dorsal  to 


THE  THENAR  SPACE 


137 


the  adductor  transversus;  of  these,  in  6  the  mass  went 
to  the  dorsum  between  the  adductor  transversus  and 
the  adductor  obliquus,  and  in  4  passed  below  or  distal 
to  the  adductor  transversus  to  lie  between  the  trans- 
versus and  first  dorsal  interosseous.  In  no  case  did 
the  mass  pass  to  the  dorsum  between  the  second  and 
third  metacarpals. 

FIG.  46 


Schematic  drawing  made  from  a  dissection  of  a  hand  in  which  the  injec- 
tion was  made  along  the  tendon  sheath  of  the  index  finger.  Mass  filled  the 
thenar  space  and  extended  along  the  lumbrical  muscle. 

Experiment  29. — Left  hand.  Tissues  well  preserved; 
mass  here  occupied  thenar  space,  and  spread  between 
adductor  transversus  and  adductor  obliquus  to  fill 
space  size  of  a  walnut  between  them  and  first  dorsal 
interosseous;  also  ruptured  through  tissues  between 
thenar  space  and  middle  palmar  space  at  the  prox- 
imal end  of  the  septum,  passed  over  to  fill  the  middle 
palmar  space,  and  accompanied  the  four  lumbricals  into 


138     SYNOVIAL  SHEATHS  AND  FASCIAL  SPACES 

their  respective  canals.     Did  not  go  under  tendons  to 
forearm. 

Experiments  30,  31,  and  32  were  the  same  as  Ex- 
periment 29,  except  that  the  mass  in  32  did  not  invade 
the  middle  palmar  space.  All  went  above  the  adductor 
transversus  to  dorsum,  however.  The  mass  in  31 
passed  along  the  middle  finger  lumbrical  and  came  to 
lie  in  the  tissue  of  the  web  immediately  beneath  the 
web.  (See  experimental  injection  drawing,  Fig.  47.) 

FIG.  47 


Schematic  drawing  made  from  a  dissection  of  a  hand  in  which  the  injec- 
tion was  made  along  the  tendon  sheath  of  the  index  finger.  Mass  filled  the 
thenar  space  and  extended  over  to  the  middle  palmar  space,  along  all  the 
lumbrical  muscles,  and  went  to  the  dorsum,  first  between  the  adductor 
transversus  and  obliquus,  and  secondly  between  the  index  and  middle  fingers. 
(See  Fig.  136  for  explanation  of  this  latter  extension.) 

Experiment  33. — This  mass  extension  was  extremely 
interesting.  It  filled  the  thenar  space  and  then  passed 
to  the  space  between  the  adductor  transversus  and  the 
first  dorsal  interosseous,  going  both  above  and  below 


THE  THEN A R  SPACE 


139 


the  adductor,  i.  e.,  both  proximal  and  distal,  abutting  on 
the  dorsal  subcutaneous  tissue  at  web  at  distal  edge  of 
first  dorsal  interosseous,  extending  along  index  lumbrical 
canal,  and  did  not  go  into  middle  palmar  space  or 
forearm.  The  most  interesting  extension,  however,  was 
that  which  occurred  through  the  palmar  aponeurosis 
at  the  distal  edge  of  the  bases  of  the  index  and  middle 

FIG.  48 


Schematic  drawing  made  from  a  dissection  of  a  hand  in  which  the  injec- 
tion was  made  along  the  tendon  sheath  of  the  index  finger.  The  mass  filled 
the  thenar  space,  extended  to  the  dorsum  below  the  adductor  transversus 
and  to  the  palm  through  a  defect  of  the  palmar  fascia. 

fingers  into  the  soft  pad  of  fatty  tissue  which  lies  here 
in  the  palm,  thus  giving  corroboration  to  those  clinical 
cases  which  are  on  record  in  which  pus  has  pointed 
here,  supposedly  through  an  imperfect  palmar  fascia. 
This  was  the  only  experimental  injection  in  which  a 
mass  appeared  in  the  palm.  (See  experimental  in- 
jection drawing,  Fig.  48.) 


140     SYNOVIAL  SHEATHS  AND  FASCIAL  SPACES 

Experiment  34. — Result  same  as  33  except  no  sub- 
dermal  palmar  extension. 

Experiment  35. — Mass  filled  thenar  space;  no  ex- 
tensions except  along  index  lumbrical  canal. 

INJECTION  THROUGH  PALMAR  FASCIA  IN  ATTEMPT 
TO  REACH  THENAR  SPACE. — To  do  this  properly  the 
cannula  should  be  inserted  about  the  middle  line  of 
the  palm  one  centimeter  to  the  thenar  side  of  the 
adduction  flexion  crease  of  the  thumb. 

FIG.  49 


Schematic  drawing  made  from  a  dissection  of  a  hand  in  which  the  injection 
was  made  through  the  palmar  fascia  into  the  thenar  space. 

Experiment  36. — Left  hand.  Cannula  inserted  into 
middle  thenaj  space,  moderate  force  used  jn  injection. 
Mass  was  found  to  have  filled  the  space  completely, 
but  had  not  followed  along  the  index  lumbrical  muscle 
to  the  finger,  nor  had  it  gone  to  the  dorsum  under  the 
subcutaneous  tissue.  The  space  filled  corresponded  to 
the  area  comprised  between  the  adduction  crease  of 
the  thumb  and  the  metacarpal  bone  of  the  thumb 
in  adduction.  (See  experimental  injection  drawing, 
Fig.  49.) 


THE  DORSAL  SUBCUTANEOUS  SPACE 


141 


Experiment  37. — Attempt  to  inject  thenar  space. 
Right  hand.  Cannula  was  inserted  too  far  to  radial 
side  over  muscular  group.  Small  mass  was  found  in 
indefinite  space  adjacent  to  flexor  brevis  pollicis.  (See 
experimental  injection  drawing,  Fig.  50.) 

Experiment  38. — Same  as  Experiment  37. 

FIG.  50 


•  Schematic  drawing  made  from  a  dissection  of  a  hand  in  which  an  attempt 
was  made  to  inject  the  thenar  space  but  in  which  the  cannula  reached  only 
one  of  the  indefinite  spaces  near  the  metacarpal  bone. 

THE  DORSAL  SUBCUTANEOUS  SPACE. 

INJECTION  OF  SUBCUTANEOUS  TISSUE  OF  THE  DOR- 
SUM  BETWEEN  THE  FlRST  AND  SECOND  METACARPALS. 

— NOTE. — These  injections  were  made  to  determine 
the  relaticn  of  these  spaces  to  the  thenar  space  and  the 
remainder  of  the  subcutaneous  tissue  on  the  dorsum. 

Experiment  39. — Injection  right  hand.  Moderate 
force;  insertion  into  subcutaneous  tissue  on  dorsum, 
thenar  region.  Mass  was  found  to  be  subcutaneous, 
and  while  there  was  evidently  a  tendency  to  limitation 
at  the  index  metacarpal,  yet  it  is  doubtful  if  it  was  due 
to  the  attachment  of  fascia  to  the  bone,  being  more 


142      SYNOVIAL  SHEATHS  AND  FASCIAL  SPACES 

likely  to  be  the  natural  tendency  to  limitation  found 
in  the  meshes  of  any  loose  tissue.  Moreover,  in  spite 
of  the  partial  limitation  at  this  point,  it  had  spread 
into  the  subcutaneous  tissue  above  the  tendons,  going 
from  the  wrist  proximally  to  the  metacarpophalangeal 
articulation  distally  and  over  to  the  level  of  the  fourth 
metacarpal  bone.  It  did  not  go  through  to  the  palm 
by  any  channel. 

Experiment  40. — Injection  of  left  hand  same  as 
above.  Mass  upon  dissection  found  to  occupy  dorsal 
thenar  subcutaneous  tissue  over  to  the  index  meta- 
carpal, beyond  which  it  did  not  extend.  It  did  not 
pass  to  the  palmar  surface  nor  into  the  thenar  space. 

INJECTION  OF  THE  SUBCUTANEOUS  TISSUE  OF  THE 
DORSUM  BETWEEN  SECOND  AND  THIRD  METACARPAL 
BONES. — Experiment  41. — Right  hand.  Cannula  in- 
serted into  subcutaneous  tissue  of  dorsum  of  hand  and 
the  mass  injected  with  considerable  force.  The  tip  of 
the  needle  was  superficial  to  the  tendons,  but  deeper 
than  the  superficial  layers  immediately  beneath  the 
skin.  Upon  dissection,  mass  was  found  to  occupy  a 
considerable  space  extending  from  the  wrist  above  to 
the  metacarpophalangeal  articulation  below  and  from 
the  metacarpal  bone  of  the  index  finger  to  the  meta- 
carpal bone  of  the  little  finger;  proximally  and  distally, 
at  the  wrist  and  fingers  respectively,  the  tissue  seemed 
to  be  bound  more  firmly  to  the  underlying  tissue  than 
laterally. 

Experiment  42. — Left  hand.  Technique  and  results 
same  as  Experiment  41.  A  study  of  these  two  show 
several  layers  of  fascia  between  the  skin  and  tendons, 
with  no  single  space  more  distinct  than  another. 

THE  DORSAL  SUBAPONEUROTIC  SPACE. 

INJECTION  UNDER  TENDONS  OF  DORSUM. — The  im- 
portance of  this  series  is  seen  when  we  remember  that 


THE  DORSAL  SUBAPONEUROTIC  SPACE 


143 


it  is  in  this  space  that  pus  would  lie  if  it  ruptured 
through  between  the  metacarpals  from  the  palmar 
surface.  The  results  obtained  were  uniform. 

FIG.  51 


Schematic  drawing  made  from  a  dissection  of  a  hand  in  which  the  injec- 
tion was  made  underneath  the  aponeurosis  of  the  dorsum,  the  subaponeurotic 
space  being  filled. 

Experiment  43. — Left  hand.  Cannula  tip  inserted 
under  tendons  between  middle  and  ring  fingers  at  lower 
third  of  dorsum.  Considerable  force  was  used  in  the 
injection.  The  mass  was  confined  to  the  space  under 
the  tendons,  i.  e.,  was  covered  by  the  tendons  and  the 
aponeurosis  between  them.  It  passed  up  to  the  wrist, 
down  to  within  one-half  inch  of  the  fingers,  and  later- 
ally to  index  metacarpal  and  little  finger  metacarpal; 
thus  having  the  shape  of  a  truncated  cone  flattened 
on  one  side.  The  mass  appeared  to  be  ready  to  break 
out  upon  the  ulnar  side,  but  none  had  done  so.  (See 
experimental  injection  drawing,  Fig.  51.) 

Experiment  44. — Left  hand.  Technique  and  results 
same  as  Experiment  43. 

Experiment  45. — Right  hand.  Cannula  inserted  be- 
tween tendons  of  ring  and  little  fingers,  at  the  middle 


144     SYNOVIAL  SHEATHS  AND  FASCIAL  SPACES 

of  the  dorsum  of  the  hand;  entire  subaponeurotic 
space  filled;  no  tendency  to  rupture  between  tendons, 
but  evidence  of  beginning  extension  at  two  sides  over 
index  metacarpal  and  little  finger. 

HYPOTHENAR  SPACE. 

Many  experiments  were  made  to  determine  the 
limitations  of  this  space.  The  injections  spread  from 
the  site  of  injection  only  after  considerable  manipula- 
tion, and  then  the  mass  was  limited  to  the  hypothenar 
area,  near  the  point  of  insertion.  The  details  of  the 
other  injections  are  omitted,  since  they  only  corrobor- 
ate the  findings  already  noted. 

RESUME  OF  PRECEDING  EXPERIMENTS  AS  TO  BOUNDARIES,  DIVER- 
TICULA,  AND  EXTENSIONS  FROM  THE  FASCIAL  SPACES.1 

That  we  may  have  a  clear  understanding  of  the 
results  obtained  by  experimental  injection,  let  us 

1  A  study  of  the  comparative  embryology  throws  some  light  upon  the  natural 
divisions  of  the  hand,  but  unfortunately  this  has  as  yet  only  been  worked  out 
in  relation  to  the  palmar  fascia  and  tendon  groups.  Dr.  McMurrich  (Am. 
Jour,  of  Anat.,  No.  2,  p.  202)  described  the  relation  of  these  in  amblystoma. 
The  muscular  masses  which  here  arise  in  the  palmar  fascia,  and  which  cor- 
respond to  the  superficial  tendons  in  the  mammalia,  divide  longitudinally  into 
three  groups,  the  lateral  parts  destined  for  the  second  and  fifth  digits,  sepa- 
rating from  the  median  parts  destined  for  the  third  and  fourth  digits.  Here  we 
see  that  thus  early  we  have  a  suggestion  of  the  ultimate  relation  of  the  parts, 
in  that  the  tendons  arising  from  the  palmar  fascia  leave  room  below  them 
for  fascial  spaces  between  them  and  the  bones.  And  again,  the  early  grouping 
of  the  tendons  corresponds  to  the  spaces,  i.  e.,  the  radial  lateral  parts  going 
to  the  index  finger,  and  being  entirely  separated  from  the  two  ulnar  parts 
corresponding  to  the  middle,  ring,  and  little  fingers.  The  most  ulnar  part 
is  not  so  distinctly  separated  from  the  median  part  as  is  the  radial,  that,  in 
a  way,  being  partly  fused  with  the  median,  but  still,  both  upon  dissection  and 
injection,  we  have  noted  a  partial  tendency  to  separation  of  the  middle  and 
ring  finger  area  from  the  little  finger  area.  How  much  the  development  of 
the  muscular  mass  of  the  hypothenar  area  may  have  to  do  with  this  is,  of 
course,  undecided,  since  we  as  yet  know  little  as  to  its  embryological  develop- 
ment, but  it  would  seem  reasonable  to  assume  that  it  has  little  relation, 
owing  to  its  extreme  ulnar  position;  so  that,  reasoning  a  posteriori,  we  would 
Say  that  in  case  of  the  mammalian  embryo  there  had  been  a  persistence  of 
the  separation  between  the  index  mass  and  the  others,  while  there  had  been 
either  an  incomplete  fusion  between  the  median  and  ulnar  mass,  or  else  they 
had  partially  fused  as  development  proceeded. 


RESUME  OF  PRECEDING  EXPERIMENTS 


145 


summarize  them.  The  mass  in  the  middle  palmar 
space,  in  practically  every  case,  filled  the  space  we  have 
outlined  (Fig.  52).  In  no  case  did  it  extend  into  the 
hypothenar  area  or  to  the  radial  side  of  the  middle 
metacarpal  bone,  except  in  the  case  noted,  where  a  band 
was  tied  about  the  wrist  in  which  the  mass  then 
ruptured  into  the  thenar  space.  In  every  case  there 


FIG.  52 


M.P.S. 


Photograph  of  middle  palmar  space,  tendons  being  raised.    The  end  of  the 
pencil  lies  in  its  deepest  part. 

was  some  extension  along  the  lumbrical  muscles, 
almost  always  going  down  between  the  bases  of  the 
middle  and  ring  fingers,  and  sometimes  between  the 
little  and  ring  fingers,  and,  more  uncommonly,  the 
middle  and  index  fingers.  Unless  great  force  was  used, 
this  was  the  limit  of  the  extension.  When  great  force 
was  used,  the  masses  in  the  lumbrical  canals  passed 

10 


146     SYNOVIAL  SHEATHS  AND  FASCIAL  SPACES 

out  into  the  loose  tissue  of  the  web;  also  the  mass  filling 
the  space  proper  passed  upward  under  the  tendons 
into  the  forearm,  where  it  spread  beneath  the  deep 
muscles  nearly  up  to  the  elbow  before  it  came  to  the 
surface  at  the  lower  part  of  the  forearm  on  the  ulnar 
side.  (For  the  location  of  the  mass  in  the  forearm,  see 
Chapters  X  and  XXVI.)  In  no  case  did  the  mass  go 
through  between  the  bones  to  the  back. 

FIG.  53 


Photograph  showing  thenar  space.     The  end  of  the  pencil  appears  in  its 

deepest  part. 

The  thenar  space  was  found  to  be  a  large  space,  but 
lying  very  deep  (Figs.  53  and  54).     It  was  not  continu- 


RESUME  OF  PRECEDING  EXPERIMENTS          147 

ous  with  the  subcutaneous  tissue  of  the  dorsum,  and 
the  mass  was  limited  at  the  free  palmar  edge  of  the 
radial  side  of  the  palm.  The  mass  did  pass,  however, 
when  force  was  used,  into  the  perimuscular  sheath  on 
the  dorsum,  passing  proximally  and  less  frequently 
distally  to  the  adductor  transversus,  lying  between 
this  muscle  and  the  first  dorsal  interosseous.  It  also 
spread  down  along  the  lumbrical  muscle  of  the  index 
finger,  making  a  diverticulum  from  one-quarter  to 
one-half  inch  long.  In  no  case  did  it  spread  up  into 

FIG.  54 


Photograph  showing  thenar  space  with  the  tendons  drawn  away  so  as  to 

expose  it  widely. 

the  forearm,  even  though  anatomical  dissection  demon- 
strated that  this  would  be  possible,  although  im- 
probable, and  if  it  did  it  would  be  in  the  same  site 
as  that  described  for  masses  coming  from  the  middle 
palmar  space.  In  no  case  did  the  mass  lie  to  the 
ulnar  side  of  the  middle  metacarpal  bone,  unless  great 
force  was  used  in  the  injection;  then  it  passed  through 
the  upper  part  of  the  septum  and  filled  the  middle 
palmar  space  in  one-third  of  the  cases. 

Injections  into  the  hypothenar  area  showed  the  spaces 


148     SYNOVIAL  SHEATHS  AND  FASCIAL  SPACES 

to  be  localized  and  perimuscular  for  the  most  part, 
not  communicating  with  any  large  space,  and  hence 
of  no  particular  surgical  importance. 

Injections  of  the  subaponeurotic  space  demonstrated 
that  the  mass  would  not  rupture  through  the  aponeu- 
rosis  unless  anatomical  exceptions  were  present.  It 
would  spread  up  to  the  wrist,  down  to  the  metacarpo- 
phalangeal  joint,  and  laterally  to  the  edge  of  the  index 
or  little  finger  tendon  on  the  radial  and  ulnar  sides 
respectively.  If  greater  force  were  used,  it  tended  to 
spread  under  the  subcutaneous  tissues,  particularly  on 
the  ulnar  side  and  at  the  knuckles. 

Injections  of  the  dorsal  subcutaneous  space  showed 
no  particular  pockets,  but  did  show  a  tendency  to 
localization  at  any  site  injected  because  of  the  obliquity 
of  fibrous  bands  crossing  from  space  to  space.  If  the 
injections  were  given  with  great  force,  the  mass  spread 
equally  in  every  direction,  except  that  there  seemed  to 
be  some  particular  factor  at  work  limiting  in  a  certain 
measure  the  spread  of  the  mass  over  the  index  meta- 
carpal  from  the  dorsum  of  the  hand  to  the  thenar 
dorsal  region,  and  vice  versa. 

Deep  injections  of  the  palm  went  into  the  spaces 
lying  underneath,  and  since  these  spaces  do  not 
overlap,  except  at  the  wrist,  only  one  space  is  affected 
by  a  given  punctured  wound.  It  must  be  remembered, 
however,  that  the  lymphatic  channels  from  the  centre 
of  the  palm  pass  deeply  into  the  tissue  and  come  to 
lie  immediately  adjacent  to  the  adductor  transversus, 
so  that  a  lymphatic  abscess  from  a  punctured  wound 
might  lie  in  the  thenar  area,  although  the  puncture 
might  appear  to  be  at  the  radial  side  of  the  middle 
palmar  space.  When  the  masses  spread  up  into  the 
forearm  they  appeared  under  the  flexor  profundus 
digitorum.  This  subject  is  considered  as  a  whole  in 
the  next  chapter,  devoted  to  a  study  of  the  various 
spaces  in  the  forearm. 


CHAPTER  X. 

ANATOMY  OF  THE  FOREARM  IN  RELATION 
TO   INFECTIONS. 

EARLY  in  my  clinical  work  it  was  found  that  there 
was  little  knowledge  as  to  the  sites  of  predilection  for 
pus  in  the  forearm  when  it  extended  from  the  hand. 
Experience  showed  that  incisions  made  at  the  sites 
suggested  by  Forssell  and  others  were  followed  by  a 
tedious  convalescence  owing  to  the  necessity  of  main- 
taining satisfactory  drainage  through  the  muscular 
bodies.  A  study  of  the  forearm  after  the  same  methods 
already  pursued  in  the  hand  was  begun,  namely, 
by  dissection  of  serial  sections  and  injection  of  masses 
from  various  sites.  As  a  result  of  this,  I  changed 
entirely  the  sites  of  my  incisions,  and  had  the  great 
satisfaction  of  seeing  cases,  which  under  the  old 
methods  of  incision  required  weeks  of  constant  at- 
tention and  multiple  incisions,  heal  in  a  week  to  ten 
days,  with  two  or  at  most  three  incisions  made  at 
one  sitting.  Parona,  as  quoted  by  Mauclaire,  has 
suggested  the  advisability  of  one  of  these  incisions — 
that  upon  the  ulnar  side  above  the  wrist. 

The  anatomical  and  experimental  data  upon  which 
these  incisions  were  based  are  detailed  in  brief  in  this 
chapter. 

ANATOMY  IN  GENERAL. 

In  general  one  should  remember  that  the  synovial 
sheaths,  i.  e.,  the  ulnar  and  radial  bursae,  pass  under 
the  annular  ligament  and  extend  into  the  forearm  for  a 
distance  varying  from  'one  to  two  inches.  The  greater 


150  ANATOMY  OF  THE  FOREARM 

part  of  the  sac  of  each  lies  upon  the  dorsal  surface  of 
the  tendons,  i.  e.,  between  the  tendons  of  the  flexor 
profundus  digitorum  and  the  pronator  quadratus 
(Fig.  91).  Again,  one  should  note  that  the  bloodvessels 
and  nerves  are  surrounded  by  fascial  spaces  and  when 
pus  once  reaches  them  it  can  spread  easily  along  these 
as  channels. 

Before  beginning  this  study  one  should  be  familiar 
with  the  general  anatomy  of  the  forearm;  particularly 
the  relations  of  the  flexor  carpi  ulnaris,  of  the  flexor 
profundus  digitorum  as  a  group,  of  the  flexor  sublimis 
digitorum  as  a  group,  of  the  course  of  the  median  and 
ulnar  nerves,  and  of  the  ulnar  and  radial  artery,  espe- 
cially the  former,  the  relation  of  the  pronator  quadratus 
and  the  ulna  and  radius  with  the  interosseous  mem- 
brane in  one  group  to  the  flexor  profundus  digitorum. 
With  these  general  facts  in  mind,  let  us  now  take  up 
the  study  of  the  cross-sections. 

SERIAL  CROSS-SECTIONS  OF  THE  FOREARM. 

The  cadaver  arms  were  hardened  in  Kaiserling  No.  I . 
After  being  sectioned  the  pieces  were  preserved  in 
Kaiserling  No.  2,  Sections  were  made  at  the  following 
distances  from  the  radial  styloid:  3  cm.,  7  cm.,  9  cm., 
and  12  cm.  The  proximal  surfaces  of  these  sections 
were  teased  out  with  a  needle  and  forceps.  The  large 
spaces  found  were  packed  with  cotton  or  held  open  with 
small  props  and  photographs  taken  to  show  their  rela- 
tion to  the  other  structures  of  the  forearm.  One  par- 
ticularly large  free  space  was  found  in  the  lower  part  of 
the  forearm  in  direct  contiguity  with  the  tendon  sheaths 
and  in  continuity  with  the  middle  palmar  space  in  the 
hand.  It  is  upon  this  that  we  will  centre  our  attention. 

Section  I  (Fig.  55). — Three  centimeters  above  radial 
styloid.  The  space  is  rather  small  here,  opening  out 
from  the  narrow  strait  that  connects  it  with  the  middle 


SERIAL  CROSS-SECTIONS  r QF  THE  FOREARM^    151 

palmar  space  in  the  hand.  It  extends  well  across  the 
forearm,  but  is  slightly  larger  upon  the  radial  side. 
The  vessels  and  nerves  are  separated  from  the  space 
by  well-defined  layers  of  muscular  and  connective 
tissue.  Upon  the  superficial  surface  it  has  the  tendons 
of  the  flexor  profundus  digitorum,  covered  by  their 
synovial  sheath,  and  the  flexor  longus  pollicis,  covered 
by  its  synovial  sheath.  On  the  radial  and  ulnar  sides 
there  is  nothing  but  the  attachment  of  the  muscular 
fascial  sheath  to  the  bones,  and  the  subcutaneous 
tissue.  On  its  deep  surface  is  seen  the  pronator 
quadratus. 

FIG-  55 


IM  - 


Section  3  cm.  above  radial  styloid:  UA,  ulnar  artery;  UN,  ulnar  nerve: 
MN,  median  nerve;  RA,  radial  artery;  S,  space;  IM,  interosseous  mem- 
brane; PQ,  pronator  quadratus. 

It  is  seen  that  if  pus  ruptured  from  the  synovial 
sheaths  or  passed  upward  from  the  middle  palmar 
space,  it  would  enter  this  free  area.  It  is  manifest  that 
a  large  accumulation  could  take  place  here.  Its  most 
superficial  sites  would  be  upon  the  sides. 

Section  2  (Figs.  56  and  57). — Five  centimeters  above 
radial  styloid.  The  relation  of  the  structures  has  not 
changed  materially.  The  body  of  the  pronator  quad- 
ratus is  somewhat  smaller.  The  space  here  goes  well 
to  the  ulnar  side. 

By  comparing  this  with  the  other  sections  it  will 
be  seen  how  little  tissue  lies  at  the  side,  and  it  is  at 


—»  <i'     V'  O  /\  O  J2  )      ]  ^ 

152  "ANATOMY.OF  THE  FOREARM 

nmT/^03TcO   nO  HDaJJO^ 


Section  5  cm,  above  radial  styloid.     ZL4,  ulnar  artery;   UN,  ulnar  nerve; 
MN,  median  nerve;  RA,  radial  artery;  S,  space;  PQ,  pronator  quadratus. 


FIG.  57 


Drawing  from  teased  cross-section,  Fig.  56:  a,  extensor  secundi  internodii 
pollicis;  b,  extensor  communis  digitorum;  c,  extensor  indicis;  d,  extensor 
minimi  digiti;  e,  extensor  carpi  ulnaris;  /,  interosseous  membrane;  g,  ulna; 
h,  pronator  quadratus;  i,  i,  flexor  carpi  ulnaris;  j,  ulnar  nerve;  k,  ulnar 
artery;  /,  flexor  profundus  digitorum;  m,  m,  flexor  sublimis  digitorum;  n, 
palmaris  longus;  o,  median  nerve;  p,  flexor  carpi  radialis;  q,  flexor  longus 
pollicis;  r,  radial  artery;  s,  space  propped  open  by  pegs  of  wood;  t,  supinator 
longus;  u,  extensor  carpi  radialis  longior;  v,  extensor  carpi  radialis  brevior; 
w,  radius;  x,  extensor  primi  internodii  pollicis. 


SERIAL  CROSS-SECTIONS  OF  THE  FOREARM     153 

this  site  that  drainage  is  instituted.  The  blocks  of 
wood  holding  open  the  space  are  about  a  centimeter 
and  a  half  in  length. 

Section  3  (Fig.  58). — Seven  centimeters  above  radial 
styloid.  In  this  section  the  pronator  quadratus  has 
almost  entirely  disappeared.  The  space  is  bounded 
below  by  the  interosseous  membrane  with  the  artery 
exposed.  The  radial  and  ulnar  arteries  and  the  median 
and  ulnar  nerves  are  still  well  separated  from  the  space. 
Attention  will  be  drawn  to  this  fact  later  in  discussing 
treatment. 

FIG.  58 


Section  7  cm.  above  radial  styloid.  Pronator  quadratus  has  almost  dis- 
appeared. Notice  that  the  vessels  and  nerves  with  the  exception  of  the 
interosseous  (I A)  are  well  separated  from  the  space. 

Section  4  (Fig.  59). — Nine  centimeters  above  radial 
styloid.  In  this  section  the  space  is  leaving  the  inter- 
osseous membrane  and  passing  toward  the  flexor  sur- 
face on  the  radial  side  of  the  deep  flexors.  It  extends 
to  the  median  nerve  and  over  to  the  ulnar  artery  and 
nerve  along  the  ulnar  side. 

This  relation  of  the  space  to  the  bloodvessels  and 
nerves  explains  why  the  injection  masses  go  up  the 
forearm  and  then  pass  in  a  retrograde  manner  toward 
the  hand  along  these  structures.  It  also  explains  those 
cases  in  which  the  injection  mass  passes  up  along 


154 

the  median  above  the  elbow.  It  helps  to  explain  the 
trophic  sequelae  and  cases  of  ulcerative  hemorrhage 
that  have  been  reported.  In  the  upper  part  of  the  fore- 
arm the  space  follows  the  nerves  and  bloodvessels  and 
becomes  indefinite.  It  is  seen  that  the  ulnar  nerve 

FIG.  59 


—IA 


Section  9  cm.  above  radial  styloid.     Note  the  relation  of  the  space  to  the 
median  nerve  and  the  ulnar  artery:  IA,  interosseous  artery. 

and  artery  along  which  the  secondary  mass  extends 
lie  immediately  under  the  junction  of  the  flexor  carpi 
ulnaris  with  the  flexor  profundus  digitorum.  This 
so  indicates  then  a  second  site  for  incision  (Figs.  122 
and  123). 


EXPERIMENTAL  INJECTIONS  OP  THE  FASCIAL  SPACES  OF 
THE  FOREARM. 

To  verify  the  findings  here,  experimental  injections 
were  made  with  plaster  of  Paris  from  various  sites 
that  might  be  the  origin  of  spreading  abscesses.  These 
will  show  the  intimate  relation  which  exists  between 
the  fascial  spaces  of  the  hand  and  the  forearm  and  those 
about  the  bloodvessels. 

It  should  be  remembered  that  we  are  only  selecting 
illustrative  experiments  which  bear  upon  the  subject 


INJECTION  OF  THE  RADIAL  BURSA  155 

in  hand,  and  that  they  do  not  by  any  means  represent 
a  complete  report  of  the  results  obtained  from  injec- 
tions at  these  various  sites. 

INJECTION  OF  THE  RADIAL  BURSA. 

Out  of  the  eight  injections  made  into  the  radial 
bursa  under  high  pressure  to  produce  rupture  and 
extravasation  of  the  mass,  six  showed  extension  from 
a  rupture  at  the  proximal  end  into  the  forearm  (see 
p.  126).  The  following  may  be  taken  as  an  example  of 
the  condition  found  upon  dissection  of  the  arm. 

Experiment  46. — Injection  under  great  pressure  of 
synovial  sheath  of  flexor  longus  pollicis  by  plaster  of 
Paris. 

Upon  dissection  the  mass  was  found  to  have  filled 
the  synovial  sheath  completely  and  ruptured  from  the 
proximal  end  into  the  tissue  of  the  forearm.  No  ex- 
tension has  taken  place  into  the  hand  either  by  rup- 
ture of  the  sheath  in  continuity  or  by  retrograde  move- 
ment from  the  forearm  under  the  annular  ligament, 
although  the  mass  had  extended  down  to  the  annular 
ligament  and  lay  under  the  superior  border.  The 
attachment  of  the  flexor  longus  pollicis  to  the  bone 
was  partially  destroyed,  owing  possibly  to  the  friability 
of  the  muscle  in  this  particular  cadaver,  but  the  mass 
showed  a  tendency  to  follow  this  muscle  and  a  pre- 
dilection for  the  radial  side  of  the  forearm.  A  portion 
of  the  mass  lay  between  the  flexor  longus  pollicis  and 
the  flexor  sublimis  digitorum.  The  larger  part,  how- 
ever, extended  underneath  the  flexor  profundus  digi- 
torum to  fill  a  space  bounded  on  the  ulnar  side  by  the 
flexor  carpi  ulnaris,  on  the  radial  side  by  the  flexor 
longus  pollicis,  dorsally  by  the  bones  with  the  inter- 
osseous  membrane  and  pronator  quadratus.  This  ex- 
tended up  to  within  three  inches  of  the  elbow-joint 
and  distally  to  the  wrist-joint.  A  great  amount  of 


156 


ANATOMY  OF  THE  FOREARM 


material  was  present.  The  area  filled  was  practically 
that  described  in  the  cross-sections,  except  that  the 
mass  did  not  extend  between  the  flexor  carpi  ulnaris 
and  the  flexor  profundus. 


FIG.  60 


X-ray  Plate. — Injection  via  tendon  sheaths  of  both  thenar  and  middle 
palmar  spaces  with  considerable  force.  Note  extension  into  forearm  from 
middle  palmar  space.  Showing  where  pus  would  lie  in  neglected  cases,  as 
in  Cases  25  and  45. 

INJECTION  OF  THE  ULNAR  BURSA. 

Injection  of  the  ulnar  bursa  resulted  frequently  in 
rupture  at  the  proximal   end.     The   mass  showed   a 


INJECTIONS  FROM  THE  MID-PALMAR  SPACE    157 

greater  predilection  for  the  ulnar  side,  and  had  a  ten- 
dency to  return  along  the  course  of  the  ulnar  artery. 
This  extension  along  the  vessel  explains  the  presence 
of  the  ulceration  of  the  vessel  and  profuse  hemorrhage 
which  occurs  at  times. 

Experiment  47. — Injection  of  the  ulnar  bursa,  rup- 
ture from  proximal  end,  filling  deep  space  in  the  fore- 
arm (Fig.  39). 

The  ulnar  bursa  was  injected  with  great  force. 
Rupture  occurred  at  the  proximal  end;  the  mass  was 
found  to  fill  space  described  above,  being  dorsal  to  the 
flexor  profundus  tendons  and  muscles.  It  showed  a 
primary  predilection  for  the  ulnar  side,  but  returned 
along  both  the  ulnar  and  radial  vessels.  There  was 
also  an  extension  along  the  median  nerve,  this  tongue 
of  plaster  following  the  nerve  to  two  inches  proximal 
to  the  elbow-joint. 

INJECTIONS  FROM  THE  MID-PALMAR  SPACE. 

What  is  the  result  when  the  mass  extends  from  the 
mid-palmar  space  of  the  hand? 

Experiment  48  (Fig.  60). — In  this  case  the  result 
is  shown  by  an  x-ray  picture.  Both  the  thenar  and 
middle  palmar  spaces  were  injected  with  force  from  the 
index  and  ring  fingers  respectively.  The  thenar  mass 
remained  in  its  usual  compartment,  while  the  middle 
palmar  mass  passed  up  under  the  group  of  flexor  ten- 
dons into  the  forearm.  Note  the  prolongations  along 
the  lumbrical  muscles,  and  the  thinness  of  the  mass 
under  the  site  of  the  annular  ligament. 

This  graphically  represents  what  has  been  suggested 
in  the  preceding  pages,  that  extension  to  the  forearm 
may  occur  from  middle  palmar  space  infections,  but 
is  not  likely  to  from  the  thenar  space. 

This  tendency  for  pus  to  extend  along  the  vessels 
and  nerves  helps  to  explain  the  frequency  of  trophic 


158  ANATOMY  OF  THE  FOREARM 

changes  which  so  often  occur  as  a  sequence  of  infections 
of  the  hand. 

Experiment  49. — Injection  with  great  force  through 
synovial  sheath  of  the  ring  finger,  filling  mid-palmar 
space  and  extending  under  anterior  annular  ligament 
into  forearm.  (See  experimental  injection  drawing, 
Fig.  61.) 

FIG.  61 


Schematic  drawing  made  from  a  dissection  of  a  hand  in  which  the  injec- 
tion was  made  along  the  tendon  sheath  of  the  ring  finger.  The  mass  filled 
the  middle  palmar  space  and  extended  along  two  of  the  lumbrical  muscles 
and  under  the  annular  ligament  into  the  forearm. 

The  mass  was  injected  with  considerable  force.  The 
middle  palmar  space  as  described  was  filled.  Thenar 
and  hypothenar  areas  free,  mass  along  little  and  ring 
finger  lumbricals  for  three-fourths  inch,  none  along 
other  fingers,  none  through  between  bones  to  back, 
mass  extended  under  tendons  strictly,  up  into  forearm, 
where  a  large  mass  was  found  lying  under  the  deep 
muscles  upon  the  pronator  quadratus  and  interosseous 


FINDINGS  BY  DISSECTION  AND  INJECTIONS     159 

septum.  It  extended  into  the  intermuscular  fascial 
spaces  up  to  the  pronator  radii  teres,  it  came  to  the 
surface  late  upon  the  radial  side  at  about  two  inches 
above  wrist,  but  the  mass  was  most  marked  upon  the 
ulnar  side  from  above  downward  between  the  flexor 
carpi  ulnaris  and  the  deep  tendons  and  muscles,  so 
that  this  upper  mass  was  most  easily  reached  by  sepa- 
rating the  flexor  carpi  ulnaris  along  its  volar  edge 
from  the  adjacent  muscular  body.  This  also  exposed 
the  ulnar  artery  and  nerve  which  were  surrounded  by 
the  mass. 

This  is  further  exemplified  by  an  x-ray  picture  taken 
of  an  arm  injected  as  shown  by  the  legend  (Fig.  60), 
the  mass  being  impregnated  with  red  lead. 


RESUME  OF  FINDINGS  BY  DISSECTION  AND  EXPERIMENTAL 

INJECTIONS. 

By  these  experiments  we  have  demonstrated  that  in 
neglected  cases,  no  matter  whether  the  pus  extends  up 
from  the  ulnar  bursa,  radial  bursa,  or  the  mid-palmar 
space,  the  same  area  of  the  forearm  is  involved,  thus 
indicating  the  position  pus  would  occupy  in  neglected 
cases,  or  in  those  cases  in  which  early  rupture  of  the 
synovial  sheaths  (ulnar  and  radial  bursa)  occurs.  This 
space  lies  under  the  flexor  profundus  digitorum  ten- 
dons and  muscle  (Fig.  62).  About  three  inches  up  on 
the  forearm  the  pus  begins  to  invade  the  intermuscular 
septa,  passing  first  to  the  area  about  the  median  nerve, 
and  later  to  the  area  about  the  ulnar  artery  and  nerve. 
Here  it  lies  between  the  flexor  carpi  ulnaris  and  the 
flexor  profundus  (Fig.  63).  This  is  about  four  inches 
up  on  the  forearm.  From  here  it  may  pass  toward 
the  elbow  along  the  vessels  and  nerves,  particularly 
the  median  nerve,  or,  more  commonly,  it  may  extend 
distally  along  the  ulnar  artery  under  the  flexor  carpi 


160 


ANATOMY  OF  THE  FOREARM 


ulnaris,  and  appear  subcutaneously  about  three  inches 
up  on  the  ulnar  side.     It  may  extend  downward  along 


FIG.  62 


UA 


Photograph  of  cross-section,  7  cm.  above  the  radial  styloid,  showing  area 

filled  with  pus. 

FIG.  63 


Photograph  of  forearm  just  below  the  middle,  showing  position  of  pus  in 
its  relation  to  the  ulnar  artery  and  nerve  and  the  median  nerve. 

the  radial  artery,  but  this  is  certainly  an  uncommon 
termination.  The  larger  part  of  the  space  is  about 
two  inches  above  the  wrist.  Its  most  superficial  parts 


FINDINGS  BY  DISSECTION  AND  INJECTIONS     161 

are  on  either  side,  just  volar  to  the  ulnar  and  radius. 
The  floor  of  the  space  is  made  up  by  the  pronator 
quadratus  at  the  wrist  and  the  interosseous  septum 
above.  The  space  may  hold  a  half  pint  or  more  of 
fluid. 

The  only  other  distinctfy  separated  space  is  that 
comprising  the  subcutaneous  tissue. 

(For  the  surgical  application  of  these  facts  see 
Chapters  XXVI  and  XXVII.) 


11 


SECTION    II. 

THE   SURGICAL   CONSIDERATION   OF   TENDON 

SHEATH    INFECTIONS  AND  FASCIAL- 

SPACE  ABSCESSES  OF  THE 

HAND  AND  FOREARM. 


CHAPTER  XI. 

PATHOGENESIS— SOURCE  OF  INVOLVEMENT 
OF  THE  TENDON  SHEATHS  AND 
FASCIAL  SPACES. 

CONCERNING  the  surgical  application  of  the  anatomi- 
cal and  experimental  data  we  have  discussed  in  the 
previous  chapters,  it  should  be  borne  in  mind  that  our 
remarks  are  strictly  confined  to  a  discussion  of  these 
facts  in  relation  to  the  subject  of  tendon  sheath  and 
fascial  abscesses  in  the  hand.  Lymphatic  infection 
will  be  considered  only  insofar  as  it  has  a  distinct 
bearing  upon  these  conditions,  a  full  discussion  being 
reserved  for  a  subsequent  chapter. 

ETIOLOGY  IN  GENERAL. 

In  all  of  the  cases  coming  under  observation,  the 
accumulations  of  pus  have  been  submitted  to  bacterio- 
logical examination,  and  the  results  differed  in  nowise 
from  the  findings  elsewhere ;  nearly  all  the  slow-growing 
abscesses  showing  the  staphylococcus  in  pure  culture, 
while  those  originating  in  the  tendon  sheaths,  if  of  a 
fulminating  nature,  showed  the  streptococcus  unless 


1 64  PA  THOGENESIS 

there  was  a  secondary  infection.  The  severity  of  the 
course  was  often  in  inverse  relation  to  the  extent  of 
the  primary  wounds.  Again,  the  general  health  and 
resistance  of  the  patient  were  often  below  normal. 
The  latter  factor  has  been  particularly  conspicuous. 
On  the  other  hand,  cases  of  localized  infection  (from 
deep  lacerated  wounds)  have  followed  in  very  robust 
individuals,  where  doubtless  the  infection  has  been 
carried  directly  to  the  space  infected.  Again,  it  has 
been  noted  that  local  trauma,  without  apparent 
abrasion  of  the  skin,  has  acted  by  lessening  the  local 
resistance,  hence  favoring  infection.  We  soon  learned 
also  that  the  older  the  patient  the  greater  would  be 
the  danger  of  a  serious  course  and  complications.  The 
gonococcus  may  be  found  in  some  cases,  almost  always 
of  hematogenous  origin. 

SOURCE  OF  INVOLVEMENT  OF  THE  VARIOUS  SHEATHS. 

Attention  has  been  drawn  above  to  the  theories 
advanced  by  the  earlier  authors  as  to  the  source  of 
infection  of  the  sheaths.  It  is  probable  that  they  may 
be  involved  either  by  lymphatic  extension  or  direct 
continuity.  The  latter,  of  course,  needs  no  discussion. 
That  wounds  involving  the  sheath  may  be  an  atrium 
and  that  abscesses  lying  in  continuity  may  cause 
necrosis  and  involvement  will  be  admitted  by  all. 
It  is  rather  uncommon  for  a  felon  to  give  rise  to 
tenosynovitis.  The  same  may  be  said  of  suppurative 
arthritis  of  the  distal  interphalangeal  joint,  and  the 
metacarpophalangeal  joint.  This  is  explained  by  the 
anatomical  relations,  which  also  probably  explain 
the  frequent  involvement  from  the  proximal  inter- 
phalangeal joint  (see  pp.  103  and  104).  I  have  seen 
extension  to  a  sheath  from  abscesses  in  a  lumbrical 
canal.  Here,  however,  the  involvement  is  likely  to 


SOURCE  OF  INVOLVEMENT  OF  VARIOUS  SHEATHS     165 

be  localized  to  the  proximal  end  of  the  finger  sheaths. 
Indeed,  this  holds  true  for  all  of  these  cases  which 
develop  as  a  result  of  abscesses  in  continuity.  One 
explanation  of  this  can  be  found  in  the  fact  that  the 
contiguous  inflammation  has  probably  given  rise  to 
plastic  adhesions  in  the  sheath  before  the  actual 
involvement  has  taken  place,  and,  again,  these  local 
accumulations  have  generally  been  produced  by  the 
staphylococcus  or  some  like  germ  of  moderate  viru- 
lence. This  is  also  true  of  involvement  of  the  ulnar 
or  radial  sheaths  secondary  to  abscesses  in  the  palm, 
as  was  exemplified  by  the  case  of  Henderson  (see 
Case  XVI). 

The  question  of  lymphatic  involvement  is  one  that 
is  not  so  easily  demonstrable,  but  any  surgeon  can 
recall  numerous  histories  of  patients  who  developed  an 
infection  of  a  sheath  within  twenty-four  to  thirty-six 
hours  after  a  simple  needle  prick  of  a  finger  upon  the 
volar  surface.  This  is  most  commonly  met  with  in 
the  distal  or  middle  phalanx  (see  Case  XI),  and  is 
almost  always  strep tococcic  in  origin.  Why  it  does 
not  occur  in  dorsal  wounds  is  understood  when  we 
remember  that  the  course  of  the  lymphatic  vessels  is 
from  the  palmar  to  the  dorsal  surface.1  It  is  this  type 
of  infection  which  presages  the  most  disastrous  results, 
since  localization  to  any  part  of  the  sheath  is  un- 
common, and  unless  early  incision  is  instituted,  necrosis 
of  the  sheath  takes  place  with  serious  local  and  con- 
stitutional sequelae.  The  possibility  of  gonococcus 
tenosynovitis  of  hematogenous  origin  must  always  be 
borne  in  mind  in  cases  with  an  obscure  origin.  Two 
such  cases  have  come  under  my  observation. 

1  Frequently  we  see  cases  of  tenosynovitis  in  which  the  patient  cannot  give 
any  history  of  injury,  the  abrasion  or  injury  having  been  so  slight  as  to  escape 
notice. 


166  PATHOGEN  ESI S 

EXTENSION  FROM  ONE  SHEATH  TO  ANOTHER. 

The  extension  from  one  sheath  to  another  follows 
strictly  on  anatomical  lines.  Apparent  exception  to 
this  is  found  in  simultaneous  involvement  of  the  thumb 
and  ulnar  bursa  without  involvement  of  the  radial 
bursa,  the  thumb  being  primary,  as  was  found  in  four 
of  Forssell  '.s  cases.  He  did  not  note  any  cases  of  little 
finger  infection  and  radial  bursitis  without  associated 
ulnar  bursitis.  Before  this  exception  is  admitted 
further  observations  must  be  made.  In  two  of  my 
cases  I  was  led  to  the  same  conclusion  on  first  open- 
ing the  sheath  of  the  flexor  longus  pollicis,  but  further 
search  revealed  pus  at  both  ends  of  the  sheath. 

The  anatomical  relations  of  the  finger  sheaths  of 
the  little  finger  and  thumb  to  the  ulnar  and  radial 
bursae  respectively,  as  well  as  the  intercommunication 
of  these  latter,  have  already  been  discussed  (see  pp. 
1 06  and  no).  When  we  are  dealing  with  an  infection 
of  little  virulence,  such  as  one  due  to  the  staphylo- 
coccus,  we  frequently  find  a  plastic  exudate  or  adhesions 
closing  the  narrowed  opening  between  these  parts  and 
the  infection  located  in  any  section;  as,  for  instance, 
the  finger  sheath,  ulnar  bursa,  radial  bursa,  or  the 
intermediary  sheaths  at  the  wrist.  Indeed,  I  have 
at  times  seen  an  infection  of  an  ulnar  bursa  limited  to 
that  part  of  the  sheath  between  the  base  of  the  finger 
and  the  annular  ligament,  the  part  of  the  sheath  in  the 
forearm  being  uninvolved,  protected  by  adhesions  at 
the  annular  ligament.  My  experience  here  agrees  with 
the  earlier  observations  of  Schwartz  and  Gosselin, 
and  differs  from  that  of  Forssell,  who  says  that  "out 
of  34  cases  of  ulnar  bursitis,  an  extension  of  the  infec- 
tion to  the  tendon  sheath  of  the  litle  finger  was  found 
in  30  cases  on  their  entrance  into  the  hospital,  and  if 
we  assume  with  Poirier  that  the  ulnar  bursa  is  com- 


EXTENSION  FROM  ONE  SHEATH  TO  ANOTHER     167 

pletely  separated  in  33  per  cent,  of  the  cases,  it  is  very 
improbable  that  a  secondary  boundary  should  in  a 
single  one  of  the  aforementioned  cases  have  developed 
through  an  adhesive  inflammation.  ...  I  have 
never,  in  operating  upon  a  suppurative  bursitis,  found 
within  the  bursa  proper  a  fibrinous  or  plastic  synovitis 
in  such  a  mass  as  to  notably  affect  the  operation." 

In  general,  however,  it  may  be  said  that  in  the 
virulent  types  of  infection  beginning  in  the  little 
finger  sheath,  we  will  almost  always  have  an  involve- 
ment of  the  ulnar  bursa  and  in  a  majority  of  cases  the 
radial  bursa  and  sheath  of  the  flexor  longus  pollicis 
will  be  involved  from  it  (see  p.  no).  The  converse 
is  also  true. 

Besides  spreading  by  direct  continuity  these  infec- 
tions may,  of  course,  involve  one  or  more  sheaths 
secondarily  by  a  rupture  from  a  previously  infected 
sheath. 

I  report  the  case  of  Mr.  P.,  who  had  an  infection  of 
the  middle  finger  tendon  sheath  which  extended  by 
way  of  the  lumbrical  canal  over  to  the  tendon  sheath 
of  the  ring  finger,  since  it  demonstrates  the  possibility 
of  such  infection  spreading  to  contiguous  tendon 
sheaths,  a  point  that  has  not  been  brought  out  in 
previous  contributions. 

CASE  VII.— Mr.  P.,  referred  by  Dr.  A.  T.  Horn. 

History:  Patient  received  slightly  lacerated  wound  on 
the  flexor  surface  of  the  middle  finger.  Inside  of  two  days 
the  finger  was  markedly  swollen  and  tender,  and  when 
seen  in  consultation  on  the  third  day  tenderness  was 
marked  throughout  the  course  of  the  tendon  sheath,  the 
finger  was  flexed  and  on  extension  presented  the  greatest 
amount  of  pain  at  the  proximal  end  of  the  sheath. 

A  diagnosis  of  tenosynovitis  was  made  and  the  tendon 

,  incised  throughout  its  length.     The  lumbrical  spaces  on 

either  side  were  involved  and  were  drained.    The  infection 

apparently  subsided,  but  on  the  seventh  day  it  was  noted 


1 68  PA  THOGENESIS 

that  the  ring  finger  was  markedly  flexed,  tender  through- 
out the  course  of  the  sheath,  and  that  on  extension  pain 
was  present  at  its  proximal  end.  The  diagnosis  of  infec- 
tion of  this  sheath  due  to  contiguity  of  the  lumbrical  space 
was  made,  and  the  tendon  sheath  was  incised  and  drained 
by  an  incision  upon  its  flexor  surface.  From  this  time 
on  there  was  an  uninterrupted  recovery  as  to  the  infection, 
but  the  ultimate  result  showed  the  patient  with  moderate 
flexion  of  the  ring  finger  at  its  proximal  interphalangeal 
joint,  no  motion  at  its  distal  joint,  and  complete  motion 
at  the  metacarpal  phalangeal  joint.  The  middle  finger 
was  held  semiflexed  with  complete  flexion  at  the  meta- 
carpophalangeal  joint;  other  joints  of  the  finger  could 
not  be  moved. 

The  extension  from  the  sheaths  by  rupture  has  been 
discussed  in  the  chapter  on  experimental  injections 
(Chapter  IX),  and  will  be  considered  in  the  subsequent 
section  upon  the  course  of  involvement  of  the  fascial 
spaces. 


SOURCE  OF  INVOLVEMENT  OF  THE  IMPORTANT  FASCIAL 
SPACES  IN  THE  HAND.      GENERAL  DISCUSSION. 

INVOLVEMENT  FROM  THE  TENDON  SHEATHS. — This 
source  is  certainly  one  of  the  most  common,  and  the 
experimental  and  anatomical  discussions  in  Chapters 
VII,  VIII,  and  IX  had  for  one  of  their  purposes  the 
determination  of  these  facts.  Accepting  the  results 
of  these  investigations  as  probabilities  only,  I  have 
been  able  to  verify  nearly  every  statement  by  clinical 
observation.  In  the  less  virulent  cases  inflammatory 
barriers  may  be  thrown  out  that  will  close  the  normal 
anatomical  canals.  If  the  process  continues  any  time, 
however,  or  the  process  is  acute,  the  result  follows 
absolutely  along  anatomical  lines. 

The  middle  palmar  space  becomes  involved  second- 
arily to  a  tendon-sheath  infection  of  the  middle,  ring, 


INVOLVEMENT  OF  FASCIAL  SPACES  IN  HAND     169 

and  little  finger.  At  times  the  middle  finger  may  rup- 
ture into  the  lumbrical  space  between  the  index  and 
middle  finger,  and  by  secondary  rupture  may  involve 
the  thenar  spaces.  But  even  in  cases  of  such  a  lumbri- 
cal rupture,  it  generally  involves  the  middle  palmar 
space. 

The  thenar  space  is  involved  as  a  result  of  rupture 
from  the  tendon  sheath  of  the  index  finger  and  excep- 
tionally from  the  middle  finger.  It  also  occurs  at 
times  that  a  rupture  of  the  flexor  longus  pollicis  sheath 
may  involve  this  space,  but  here  the  pus  is  more 
likely  to  come  to  the  surface  at  the  web. 

The  lumbrical  spaces  are  most  commonly  the  site 
of  the  primary  focus  after  rupture  from  the  proximal 
end  of  the  various  sheaths.  The  middle  and  ring 
fingers  may  rupture  on  either  or  both  sides.  The  index 
finger  most  commonly  ruptures  to  the  ulnar  side,  but 
may  rupture  upon  the  radial  side,  while  the  little 
finger  sheath  ruptures  only  upon  its  radial  side. 

Infection  of  the  dorsal  tendon  sheaths  is  so  uncom- 
mon that  prognostic  data  here  would  not  be  of  any 
value. 

DIRECT  IMPLANTATION  OF  THE  INFECTION  IN  THE 
SPACES. — The  middle  palmar  space  is  more  often  in- 
fected by  implantation,  both  through  direct  puncture 
and  extensive  crushing  injuries  and  lacerated  wounds. 

CASE  VIII. — Crushing  injury  of  hand;  fracture  of  ring 
finger  metacarpal,  with  infection  involving  the  middle 
palmar  space. 

Mr.  B.  P.,  aged  twenty-five  years,  Chicago  Charity 
Hospital. 

Patient 's  Statement :  Patient  states  that  he  was  thrown 
in  front  of  a  moving  car  and  the  wheel  ran  on  his  hand, 
but  evidently  did  not  cross  it.  Condition  found  upon 
entrance  to  hospital  on  following  day:  Lacerated  wounds 
across  dorsum  of  right  hand,  midway,  two  and  one-half 


170  PATHOGENESIS 

inches  long,  rather  deep,  into  subcutaneous  tissue;  lacer- 
ated wound  of  palmar  surface  two  inches  long  and  irreg- 
ular, so  that  there  was  a  flap  raised  up  consisting  of  tissue 
superficial  to  palmar  aponeurosis;  wounds  infected;  frac- 
ture of  metacarpal  of  middle  finger;  tendons  intact; 
fingers  extended;  not  particularly  tender  to  flexion  and 
extension,  although  thumb  was  more  tender  than  others. 
(This  was  later  found  to  be  due  to  a  fracture  of  the  proxi- 
mal phalanx).  Whole  hand  swollen,  no  particular  areas. 
Flaps  opened  to  allow  drainage.  Hot  boric  dressingsapplied. 

Patient's  temperature  and  pulse  demonstrated  a  con- 
tinuation of  the  severe  infection,  and  two  weeks  after 
entrance,  owing  to  the  site  of  the  injury  and  the  greater 
rigidity  of  the  middle,  ring,  and  little  fingers,  a  diagnosis 
of  pus  in  the  middle  palmar  space  was  made.  Proximal 
phalanx  extended,  two  distal  phalanges  flexed  45  degrees 
from  the  same  line.  Incision  into  middle  palmar  space 
disclosed  abscess  there  in  communication  with  the  frac- 
tured metacarpal.  Through-and- through  drainage  from 
palm  to  dorsum  instituted.  Rapid  fall  of  temperature  and 
pulse  followed.  Drainage  was  free.  Edema  and  swelling 
continued  for  some  time,  beginning  to  decrease,  however, 
at  the  end  of  the  first  week. 

January  29  (second  day).  Temperature  101.5°  to 
102^°;  pulse,  70  to  104. 

January  30.  Temperature,  101°  to  103.25°;  pulse,  80 
to  108. 

February  I.  Temperature,  101.5°  to  101.25°;  pulse, 
100  to  1 08. 

February  3.  Temperature,  99°  to  99^°;  pulse,  92  to 
104. 

February  4.  Temperature,  98^°  to  99.5°;  pulse,  80  to 
92. 

February  6.  Temperature,  99.5°  to  102.5°;  pulse,  88 
to  92. 

Here  the  infection  evidently  extended. 

February  9.  Temperature,  100.5°  to  101^°;  pulse,  84 
to  90. 

February  n.  Temperature,  99.25°  to  104!°;  pulse,  84 
to  92. 

February  13.  Temperature,  100°  to  103.25°;  pulse,  96 
to  124. 


INVOLVEMENT  OF  FASCIAL  SPACES  IN  HAND    171 


February  15.  Temperature,  100.25°  to  ioi£°;  pulse, 
76  to  90. 

Operation:  Middle  palmar  space  drained. 

February  17.  Temperature,  99.25°  to  100.5°;  pulse, 
96  to  100. 

Temperature  curve  begins  to  fall  and  septic  symptoms 
decrease.  Sleeps  well  and  begins  to  eat. 

February  19.  Temperature,  99.5°  to  101.25°;  pulse, 
92  to  96. 

February  22.  Temperature,  99^°  to  101°;  pulse,  94 
to  96. 

Drain  removed. 

Gradual  fall  until  March  3,  when  the  temperature  fell 
to  normal  and  remained  there. 

March  20.  Temperature  and  pulse  normal;  hand  still 
swollen  and  little  movement  in  fingers;  position  of  digits 
same  as  upon  extrance;  can  move  all  slightly  without 
pain,  index  most  of  all;  thumb  slightly  tender  to  passive 
movements  (fractured).  Other  fingers:  little  pain  pro- 
duced by  manipulation. 

April  20.  Hand  improved  much;  much  greater  range 
of  movement  of  fingers;  evident  that  nearly  full  functions 
will  be  restored. 

In  deciding,  however,  whether  or  not  the  middle 
palmar  space  has  been  invaded  by  injury,  it  is  well  to 
bear  in  mind  that  the  space  lies  dorsal  to  the  tendons 
and  superficial  vessels;  hence  these  can  be  uncovered 
by  a  lacerated  wound,  and  the  space  not  necessarily 
become  involved,  although  it  is  probably  true  that 
unless  scrupulous  care  be  taken  to  give  perfect  drain- 
age superficially,  the  space  will  later  become  involved, 
since  the  fascial  sheet  separating  the  tendons  from  the 
space  is  very  thin,  as  has  already  been  pointed  out. 
This  same  fact  is  to  be  remembered  in  case  of  a 
punctured  wound,  since  while  the  loose  cellular  tissue 
surrounding  the  tendons,  superficial  vessels,  and  the 
lumbrical  muscles  would  harbor  pus  for  a  short  time, 
if  properly  drained  it  need  not  extend  to  the  space. 


172  PATHOGEN  ESI  S 

If  intervention  is  withheld  for  any  length  of  time  it 
must  extend  either  down  along  the  lumbrical  muscles, 
through  the  fibrous  canal  at  the  distal  part  of  the  palm 
already  noted,  and  thence  into  the  cellular  tissue  dor- 
sal to  the  web,  or  break  into  the  palmar  space,  and  in 
nearly  every  case  the  latter  result  will  be  found  to 
have  occurred  long  before  the  former. 

Owing  to  the  juxtaposition  of  the  metacarpal  bones, 
particularly  of  the  middle  and  ring  fingers,  any  crush- 
ing injury  of  the  hand,  with  consequent  compound 
fracture  of  these  bones,  will  frequently  lead  to  infec- 
tion through  this  dorsal  wound,  as  I  myself  have  seen 
(Case  VIII).  The  metacarpal  bone  of  the  little  finger, 
being  somewhat  distant  from  the  space,  is  not  so  likely 
to  open  the  space,  while  the  metacarpal  bone  of  the 
index  finger  (and  in  exceptional  conditions  the  middle 
finger)  will  open  the  thenar  space.  Compound  frac- 
ture of  the  thumb  metacarpal  would  more  likely  lead 
to  dorsal  subcutaneous  accumulations  of  pus,  or  even 
synovial  infection  of  the  sheath  of  the  flexor  longus 
pollicis,  than  thenar-space  infection.  It  is  well  to  bear 
these  predisposing  etiological  factors  in  mind  when  we 
come  to  discuss  the  diagnosis  of  the  position  of  the 
pus. 

Since  few  lymphatics  lead  into  the  hypothenar  space, 
and  it  is  isolated  from  adjacent  areas  by  densely 
circumscribed  tissue,  infection  here  is  due  most  often 
to  direct  implantation.  For  instance,  a  palmar  in- 
fection will  rupture  into  the  ulnar  bursa  or  extend, 
in  preference,  under  the  annular  ligament,  and  then 
rupture  into  the  cellular  spaces  of  the  forearm,  before 
it  will  overcome  the  resistant  tissue  intervening  be- 
tween it  and  the  hypothenar  space  (see  cross-sections, 
Figs.  24  and  25).  The  space  can  be  infected,  however, 
from  the  dorsum,  through  a  compound  fracture  of 
the  fifth  metacarpal,  but  even  there  the  pus  would 


INVOLVEMENT  OF  FASCIAL  SPACES  IN  HAND     173 

be  more  likely  to  accumulate  upon  the  dorsum,  owing 
to  the  intimate  relation  of  the  hypothenar  muscles  to 
the  bone,  than  in  the  space,  unless  the  injury  of  the 
muscles  is  extensive. 

Direct  infection  of  the  subaponeurotic  space  can  occur 
by  punctured  or  incised  wounds,  or  by  crushing  in- 
juries compounded  particularly  upon  the  dorsum.  The 
incised  wounds,  lying  transverse  to  the  tendons,  would 
be  less  likely  to  lead  to  subaponeurotic  accumulations 
of  pus,  owing  to  the  retraction  of  the  aponeurosis  by 
the  extensor  muscles,  thus  opening  the  gap  widely 
so  that  free  drainage  would  ensue  into  the  subcutaneous 
tissue  or  externally.  Longitudinal  cuts,  on  the  con- 
trary, would  tend  to  close,  and  thus  prevent  free 
drainage. 

The  subcutaneous  tissue  is  infected  in  the  same  man- 
ner. It  also  can  be  invaded  in  the  pileous  infections 
occurring  upon  the  dorsum,  which  at  times  become 
carbuncular  in  their  nature,  thus  extending  from  the 
skin  proper  into  the  subcutaneous  tissue. 

INVOLVEMENT  BY  LYMPHATIC  EXTENSION. — Besides 
the  direct  infection  of  these  spaces,  they  may  become 
involved  by  an  extension  from  adjacent  injuries,  either 
through  the  lymphatics,  or  by  continuity  of  fascial 
spaces.  There  is  abundant  clinical  proof  that  infection 
by  the  less  virulent  germs  can  spread  by  lymphatic 
channels,  and  abscesses  develop  at  distant  spots.  Upon 
the  other  hand,  it  is  often  impossible  to  say  whether 
an  extension  has  occurred  by  means  of  the  lymphatic 
vessels,  or  by  means  of  the  spaces,  and  fortunately  in 
these  cases  it  is  not  necessary  to  decide  the  question, 
since  the  two  courses  are  generally  side  by  side.  Thus, 
the  deep  lymphatics  pass  from  the  fingers  along  with 
the  vessels  in  the  same  space  in  which  the  lumbrical 
muscle  lies,  and  in  a  given  case,  for  instance,  an  infec- 
tion at  the  base  of  the  ring  finger  which  spreads  into 


174  PATHOGEN  ESIS 

the  middle  palmar  space,  who  can  say  whether  it 
extends  by  means  of  the  lymph  vessel  or  along  the 
lumbrical  muscle,  going  to  the  radial  side  of  that 
finger?  Moreover,  we  do  not  need  to  know.  What  is 
of  importance  is  to  know  where  the  pus  lies  after  it 
has  extended,  and  certainly  a  study  of  the  course  of 
the  lymphatic  channels  is  of  importance  in  relation 
to  this.  It  is  not  our  purpose  to  discuss  the  subject 
of  lymphatic  infection  as  a  whole,  nor  do  more  than 
draw  attention  to  the  monumental  work  of  Sappey, 
Leaf,  Malgaine,  and  others,  by  which  we  can,  in  some 
measure,  prognosticate  the  position  of  a  metastatic 
abscess  when  the  point  of  primary  infection  is  known. 
The  subject  as  a  whole  will  be  discussed  in  a  subsequent 
chapter. 

The  superficial  lymphatics  upon  the  palmar  surface 
pursue  the  shortest  course  to  the  dorsum.  Thus,  for 
instance,  an  infection  starting  upon  the  distal  part 
of  the  palm  would  go  between  the  web  of  the  fingers 
to  the  subcutaneous  tissue  of  the  dorsum.  Hence, 
should  an  abscess  develop  as  a  result  of  this,  it  would 
be  found  in  the  dorsal  subcutaneous  area.  Should  a 
lymphangitis  be  present,  however,  without  localized 
abscess  formation,  the  swelling  in  this  region  would 
be  just  as  great,  owing  to  the  edema  which  develops 
in  the  loose  tissue  found  here.  This  will  be  brought 
out  later  in  discussing  the  diagnosis.  Should  the  deep 
lymphatics  be  involved,  the  infection  will  follow  the 
deeper  vessels,  hence  passing  into  the  palm.  Theo- 
retically speaking,  then,  an  infection  spreading  from 
the  adjacent  sides  of  the  little  and  ring  finger,  and  the 
ring  and  middle  fingers,  would  lead  to  an  accumulation 
of  pus  in  the  middle  palmar  space,  while  an  infection 
of  the  adjacent  sides  of  the  middle  and  index  fingers 
and  index  and  thumb  would  infect  the  thenar  space. 
Other  infections  upon  these  fingers  more  dorsal  would 


INVOLVEMENT  OF  FASCIAL  SPACES  IN  HAND     175 

follow  the  deep  vessels  under  the  aponeurosis  upon  the 
back  of  the  hand,  thus  producing  a  subaponeurotic 
abscess.  Unfortunately,  sufficient  clinical  evidence 
has  not  accumulated  to  prove  these  assumptions, 
although  some  cases  have  been  reported  which  tend 
to  support  them.  Chevalet  and  Dolbeau,  particularly, 
have  presented  cases  showing  this  complication,  espe- 
cially those  showing  extension  and  development  of 
abscesses  under  the  dorsal  aponeurosis.  The  proof 
of  an  extension  to  the  palmar  and  thenar  spaces  is 
much  harder  to  demonstrate,  for  the  reasons  that 
have  already  been  pointed  out.  But  with  the  accurate 
outlines  of  the  spaces  that  we  have  shown  in  mind, 
it  is  to  be  hoped  that  the  future  will  enable  us  to  be 
more  definite  upon  this  point. 

Dolbeau  has  drawn  attention  to  the  frequency  of 
infection  along  the  course  of  the  radial  in  the  forearm, 
due  to  extension  from  the  thenar  region,  by  means  of 
the  radial  lymphatics.  He  also  notes  the  presence  of 
abscesses  along  the  ulnar  artery  and  in  the  deep  tissues 
in  the  forearm,  originating,  he  believes,  by  a  lymphatic 
extension  along  the  anterior  interosseous.  That  these 
all  occur  is  not  only  possible,  but  probable;  but  in  this 
connection  the  reader  will  remember  the  experimental 
injections  of  the  palmar  space,  and  the  ulnar  and  radial 
bursae  where  the  mass  spread  by  continuity  of  tissue, 
under  the  tendons  into  this  middle  foyer,  and  then 
involved,  secondarily,  both  the  radial  and  ulnar  areas 
mentioned  (Experiments  46  to  49),  demonstrating  that 
the  same  clinical  signs  and  pathological  condition  can 
be  produced  by  fascial  space  or  synovial  sheath  exten- 
sion as  by  the  lymphatic  course,  except  those  cases  in 
which  the  radial  and  ulnar  foyers  are  the  primary 
source,  or  are  alone  involved. 

EXTENSION  FROM  ONE  FASCIAL  SPACE  TO  ANOTHER. 
—In  the  preceding  section  we  have  answered  the  ques- 


176  PATHOGEN  ESIS 

tion  as  to  the  source  of  involvement  of  the  various 
spaces.  We  now  arrive  at  the  next  question  which 
confronts  the  surgeon.  With  a  given  space  already 
involved,  to  what  other  spaces  could  the  infection  ex- 
tend, and  by  what  course?  The  question  now  becomes 
one  more  of  pathology  than  anatomy,  and  while  the 
infection  still  retains  its  full  relation  to  the  anatomical 
peculiarities  of  a  part,  yet  the  destruction  of  tissue 
incident  to  long  inflammation  must  be  taken  into 
consideration.  The  longer  one  studies  the  question 
the  more  prone  he  is  to  ask  whether  many  of  the  com- 
plicating extensions  are  not  due  either  to  inadequate 
treatment,  or  an  improper  idea  as  to  the  position  of 
the  pus,  and  consequently  the  institution  of  incisions 
which  tend  to  favor  the  extension  of  the  infection  as 
much  as  to  give  proper  drainage. 

Let  us  take  the  palmar  space.  Here  the  question 
of  extension  has  been  studied  by  injection.  The  pus 
would  have  a  natural  tendency  to  spread  in  two  ways: 
First,  along  the  lumbrical  muscles  of  the  little,  ring, 
and  middle  fingers,  and  thus  point,  in  time,  in  the  con- 
nective tissue  of  the  web  upon  the  dorsum.  This  we 
know  has  occurred  in  long-standing  cases,  in  spite  of 
the  pseudoclosure  of  the  canal  at  the  lower  end  and 
its  narrowness,  which  would  thus  favor  closure  by 
inflammatory  exudate  (see  x-ray  plate,  Fig.  41,  and 
schematic  drawings,  Figs.  39  and  45).  Secondly,  the 
pus  would  tend  to  pass  under  the  annular  ligament 
behind  the  tendons,  immediately  over  the  wrist-joint, 
thence  into  the  forearm,  lying  upon  the  radius,  ulna, 
interosseous  membrane,  and  its  attached  muscles,  and 
the  pronator  quadratus,  covered  by  the  flexor  pro- 
fundus  digitorum,  thus  filling  the  entire  space  from  the 
elbow  to  the  wrist  before  it  comes  to  the  surface  later- 
ally two  to  three  inches  above  the  wrist-joint  (Experi- 
ment 49).  This  extension  would  take  place  in  at  least 


two-thirds  of  the  injections  of  the  palmar  space  if 
force  were  used.  But  now  enters  the  question  of 
destruction  of  tissue  at  the  wrist-joint,  swelling  of  the 
tissues  under  the  annular  ligament,  and  the  plastic 
exudate,  which  would  tend  to  close  this  natural  exit. 
That  this  occurs  in  a  majority  of  the  cases  we  have 
abundant  clinical  evidence.  I  have  not  had  a  single 
case  in  which  pus  extended  from  the  middle  palmar 
space  to  the  forearm,  but  in  corroboration  of  the  experi- 
mental data  we  find  the  report  of  a  postmortem  done 
by  Professor  Dolbeau,  and  reported  by  Chevalet  in  his 
Paris  thesis  of  1875.  The  extension  under  the  syno- 
vial  sheath,  without  invading  it,  and  the  involvement 
of  the  forearm,  with  its  diverticulum  along  the  radial, 
all  make  a  picture  the  duplicate  of  Experiment  49.  It 
will  be  noted  that  the  pus  occupies  the  exact  outlines 
of  the  middle  palmar  space,  bathes  the  free  portions 
of  the  tendons  in  juxtaposition  to  the  palmar  aponeu- 
rosis,  and  yet  it  is  specifically  stated  that  the  abscess 
cavity  lay  dorsal  to  the  tendons. 

CASE  IX. — "At  the  hand  the  lesion  is  limited  to  the 
middle  palmar  region;  the  two  eminences,  thenar  and 
hypothenar,  are  intact.  In  the  middle  palmar  region  the 
aponeurosis  is  raised  with  some  difficulty,  the  tissues, 
infiltrated  with  plastic  matter,  form  a  thick  layer  as  if 
lardaceous,  in  the  deep  part  of  which  are  plunged  the 
superficial  palmar  arch  and  the  terminal  ramifications 
of  the  median  nerve. 

"These  organs  being  dissected  and  raised,  one  begins 
to  uncover  the  tendons  in  their  palmar  portion,  and  in 
order  to  be  able  to  examine  them  in  their  whole  length, 
the  annular  ligament  of  the  carpus  is  incised. 

"The  sheath  of  the  tendon  of  the  long  flexor  of  the 
thumb  is  intact  in  all  its  length,  at  the  thumb,  at  the 
palm  of  the  hand,  under  the  annular  ligament,  and  above 
this  ligament  the  cul-de-sac  by  which  it  terminates.  Let 
us  recall  that  it  is  upon  the  thumb  that  the  initial  wound 

12 


178  PATHOGEN  ESIS 

is  found,  the  point  of  departure  of  all  the  trouble.     But 
the  sheath  of  the  flexor  longus  pollicis  is  absolutely  intact. 

"In  examining  the  ulnar  sheath  one  finds  the  follow- 
ing: The  portion  of  this  sheath  destined  to  cover  the 
tendons  of  the  superficial  flexor  is  little  altered,  and  these 
tendons,  save  that  of  the  little  finger,  are  relatively  intact. 
The  portion  of  the  sheath  destined  to  the  tendons  of  the 
deep  flexor  is  much  more  diseased,  especially  at  the  level  of 
the  tendon  of  the  little  finger.  In  examining  the  sheath 
of  this  tendon,  one  finds  it  intact  in  its  digital  portion. 
The  tendon  presents  there  its  mother-of-pearl  appearance, 
and  is  absolutely  sound.  But  if  one  follows  it  to  the  palm 
of  the  hand,  one  sees  it  penetrate  into  a  purulent  foyer, 
which  occupies  the  deep  part  of  the  hand.  The  tissue 
about  bathed  in  pus  is  diseased.  Likewise  the  tendons 
which  it  envelops  for  a  stretch  of  about  4  cm.  of  the  tendon 
of  the  little  finger,  of  2.5  cm.  to  3  cm.  of  the  other  tendons, 
index,  middle,  and  ring.  Above  this  point  the  sheath  and 
the  tendons  take  again  their  character  of  integrity  and 
keep  it  in  the  carpal  canal,  even  to  the  terminal  cul-de-sac 
of  the  sheath. 

"In  raising  the  tendons  of  the  deep  flexor,  one  begins  to 
uncover  a  purulent  foyer  occupying  the  profound  palmar 
region,  situated  exactly  upon  a  median  line  (par  rapport) 
in  relation  to  the  axis  of  the  hand,  and  corresponding 
exactly  to  the  deep  palmar  arch  that  one  sees  placed 
against  its  posterior  wall.  Its  anterior  wall  is  formed  by 
the  sheath  of  the  deep  flexor  tendons  that  it  flooded  over. 
It  is  prolonged  the  length  of  the  sheath  of  the  tendon  of 
the  little  finger,  had  opened  it  and  pus  had  penetrated 
and  traversed  it  in  such  a  manner  as  to  come  to  show  itself 
beneath  the  palmar  aponeurosis;  but  a  thing  to  notice, 
it  had  not  spread  into  this  sheath,  neither  at  the  lower 
part,  toward  the  little  finger,  nor  in  the  upper  part  in 
the  carpal  canal. 

"The  radiocarpal  articulation  is  filled  with  pus;  its 
cartilages  are  destroyed,  the  osseous  surfaces  which  sup- 
ported them  are  eroded.  The  triangular  ligament  partly 
destroyed  allows  the  radiocarpal  articulation  to  com- 
municate freely  with  the  inferior  radiocubital  articulation. 

"The  articulation  of  the  first  row  of  the  carpal  with 
the  second  is  in  the  same  condition;  likewise  the  articu- 


INVOLVEMENT  OF  FASCIAL  SPACES  IN  HAND     179 

lation  of  the  bones  of  each  row  between  them,  especially 
of  the  first.  What  is  the  origin,  what  has  been  the  mode 
of  production  of  this  suppurative  arthritis  of  the  wrist? 
It  is  a  question  not  easy  to  decide,  but  that  which  can  be 
affirmed  is  that  the  lesion  so  limited  by  the  sheath  has 
not  been  there  for  nothing,  since  this  sheath  is  intact  at 
the  level  of  the  articulation. 

"In  dissecting  the  forearm,  one  is  struck,  first  of  all, 
by  the  apparent  integrity  of  its  anterior  region.  The 
lesions  are,  in  fact,  very  deep.  Alone,  the  sheath  of  the 
radial  vessels  appears  diseased  from  the  first  inspection. 
It  is,  in  the  interior  half  of  the  forearm  region,  infiltrated 
with  a  plastic  matter  which  gives  to  it  the  appearance  of 
a  whitened  cord  with  granulated  surface.  The  artery, 
plunged  in  the  middle  of  this  plastic  matter,  is  detached 
from  it  only  with  difficulty,  and  by  dissecting  it  with  care. 
The  sheath  of  the  ulnar  is  intact;  the  median  nerve 
presents  nothing  at  all  particular;  the  muscles  are  intact 
also,  at  least  those  of  the  superficial  layers,  because  in 
dissecting  the  deep  flexor  one  finds  beneath  it,  or  rather 
in  its  thickness,  in  front  of  and  inside  of  the  ulnar  bone,  a 
purulent  foyer  of  about  the  volume  of  a  small  egg.  This 
foyer,  situated  at  the  middle  part  of  the  forearm,  well 
limited  below,  at  least  upon  the  anterior  region  of  the 
forearm,  is  without  communication  with  the  lesion  of  the 
palm  of  the  hand,  and,  with  that  which  we  shall  see 
presently,  exists  at  the  level  of  the  pronator  quadratus. 
In  seeking  what  has  been  its  point  of  departure,  one  finds 
it  at  the  side  of  the  ulnar  bone.  This  latter  has  been  the 
seat,  in  its  inferior  half,  of  the  suppurative  periostitis, 
and  is  almost  totally  denuded,  even  to  the  middle  of  its 
length.  The  foyer  that  we  have  just  indicated  is  a  tributary 
of  the  subperiosteal  foyer,  which  bathes  the  bone  from  the 
back  and  the  inside.  The  origin  of  this  periostitis  appears 
to  have  been  the  rupture  of  the  articulation  full  of  pus, 
which  was  opened  from  the  back. 

"In  raising,  at  the  wrist,  all  the  tendons,  the  flexors, 
one  begins  to  uncover  a  second  foyer  situated  between 
these  tendons  and  the  pronator  quadratus.  This  muscle 
altered  but  not  destroyed,  separates  this  foyer  from  the 
ulnar  bone,  so  that  there  exists  no  relation  between  it 
and  the  osseous  lesion.  On  the  contrary,  this  foyer  com- 


180  PATHOGEN  ESI  S 

municates  by  the  proper  canal,  behind  the  sheaths  of  the 
tendon,  with  the  palmar  foyer." 

We  now  ask  ourselves,  What  are  the  probabilities 
for  extension  when  these  normal  exits  are  closed?  In 
what  way  will  the  inflammatory  destruction  of  barriers 
show  itself?  The  pus  cannot  break  through  the  firm 
palmar  aponeurosis.  We  first  turn  our  attention  to 
the  adjacent  thenar  space.  We  remember  that  the 
lower,  or  distal  portion  of  the  intervening  wall  is  very 
firm,  but  that  at  the  proximal  end,  the  dividing  tissue 
is  rather  thin,  and  it  is  very  easy  to  suppose  that 
the  infection  may  destroy  this  and  thus  invade  the 
radial  side.  Experimentally,  this  can  be  seen  to  occur. 
(See  Experiment  20,  Fig.  41.)  This,  however,  would  not 
occur  until  late,  since  most  of  the  pus  is  at  the  distal 
part  of  the  hand.  But  that  it  does  occur  frequently 
in  neglected  cases  I  have  abundant  clinical  evidence. 
It  is  one  of  the  most  common  of  the  extensions. 

Again,  the  pus  might  extend  along  the  lumbrical 
muscle  of  the  middle  finger,  and  rupture  from  here 
into  the  thenar  area. 

Upon  the  hypothenar  side  there  is  so  much  tissue 
intervening  between  the  middle  palmar  space  and  the 
hypothenar  that  we  would  expect  this  to  become 
involved  only  in  exceptional  cases. 

Text-books  all  tell  us  that  the  pus  in  these  cases 
finds  exits  between  the  metacarpal  bones,  and  thus 
escapes  to  the  dorsum.  When  one  studies  the  dense 
layer  of  fascia  spreading  from  bone  to  bone,  upon  both 
the  volar  and  dorsal  surfaces,  being  really  an  anterior 
and  posterior  interosseous  membrane,  with  the  inter- 
osseous  muscles  between,  and  a  division  between  them 
being  often  difficult  to  find,  we  are  led  to  wonder  if 
this  complication  really  occurs  as  early  in  the  course 
of  the  disease  as  we  are  led  to  believe.  Whether  often 


INVOLVEMENT  OF  FASCIAL  SPACES  IN  HAND     181 

the  edema  upon  the  dorsum  may  not  have  been  mis- 
taken for  pus,  and  the  spurious  corroboration  obtained 
by  through-and- through  drainage  misinterpreted.  By 
no  means  can  it  be  denied  that  at  times,  later  in  the 
course,  the  pus  does  find  this  means  of  exit.  When 
it  does,  it  first  comes  to  lie  in  the  subaponeurotic, 
and  then  in  the  subcutaneous  tissue.  I  personally 
have  never  seen  such  a  case  unless  there  was  an  osteo- 
myelitis of  the  metacarpals  or  carpal  bones,  and  I 
believe  it  to  be  uncommon. 

Another  cause  of  extension  is  sometimes  seen  in 
which  the  ulnar  bursal  sheath  is  destroyed,  and  pus 
thus  enters  the  sac,  spreads  along  the  tendons,  and 
ruptures  into  the  forearm  in  the  same  space  we  have 
already  described  as  lying  under  the  flexor  profundus. 

Suppose  our  thenar  space  to  be  primarily  involved; 
the  pus  here  does  not  so  readily  extend  into  the  fore- 
arm. (See  experiments  forcible,  Nos.  29  to  33.)  Here 
probably  the  weakest  place  lies  toward  the  dorsum, 
either  above  or  below  the  adductor  transversus,  thus 
invading  the  tissue  between  the  thumb  and  index 
metacarpal,  and  between  the  adductor  transversus  and 
first  dorsal  interosseous,  where  there  is  a  large,  cone- 
shaped  cavity.  (See  Experiments  Nos.  29  to  32.)  It 
should  be  borne  in  mind,  however,  that  this  result  is 
not  obtained  easily,  since  the  pus  will  often  remain 
for  days  confined  to  the  thenar  space  (Case  X).  In 
long-continued  or  anomalous  cases  it  can  spread  up 
along  the  lumbrical  muscles  of  the  index  finger,  infect 
the  loose  connective  tissue  about  the  palmar  tendons, 
and  thus  infect  the  palmar  space,  or  can  rupture 
through  at  the  upper  end.  (See  Experiments  29  to  35.) 
This  complication  should  be  rare,  however,  in  properly 
treated  cases. 

In  case  the  subaponeurotic  space  is  infected  by 
extension  from  the  palmar  space  or  otherwise,  there 


182 


PATHOGEN  ESI  S 


might  be  considerable  variation  in  the  course  the  pus 
would  pursue;  if  the  sheet  is  dense,  as  it  is  in  a  majority 
of  cases,  the  suppurative  process  would  tend  to  extend 
under  the  aponeurosis  and  point  laterally,  upon  either 
side,  at  the  thinner  tissue  there,  thus  becoming  subcu- 
taneous, or  at  the  distal  margin  between  the  metacar- 

FIG.  64 


^^^Ki^^MHi^^^^^^^^^^H^^^^B^M^H^B^H^^HK^BH^M^H^HBKH^H^^M^BH 

Scars  showing  where  subaponeurotic  abscess  has  pointed.  Note  four 
openings  at  the  edge  of  the  aponeurotic  sheet.  Note  prominence  of  tendons, 
i.  e.,  suppuration  beneath. 

pophalangeal  joints,  as  I  myself  have  seen.  However, 
at  times  there  are  thin  places  between  the  tendons, 
and  then  the  purulent  matter  would  become  sub- 
cutaneous through  this  small  opening.  In  all  prob- 
ability, however,  before  any  of  these  things  happen, 
operative  interference  will  have  opened  the  abscess 
(Fig.  64). 


INVOLVEMENT  OF  FASCIAL  SPACES  IN  HAND     183 

• 

RECAPITULATION  AS  TO  SOURCE  OF  INVOLVEMENT 
OF  THE  FASCIAL  SPACES. — Given  a  distinct  space,  from 
what  source,  in  a  majority  of  cases,  is  it  likely  to  become 
involved,  leaving  out  of  consideration  direct  implanta- 
tion of  infection? 

The  middle  palmar  space  would  receive  infection 
from  the  middle  finger,  ring  finger,  and  radial  side  of 
the  little  finger,  with  their  synovial  sheaths  and  the 
corresponding  lumbrical  muscle  spaces.  Osteomyelitis 
of  the  middle  or  ring  metacarpals  would  also  extend 
to  this  space. 

The  thenar  space  would  become  involved  by  infec- 
tion from  the  index  finger  and  the  ulnar  side  of  the 
thumb  and  their  synovial  sheaths,  especially  that  of 
the  index  finger  and  the  index  lumbrical  space.  Osteo- 
myelitis of  the  index  and  thumb  metacarpals  could  also 
involve  this  space,  although  it  would  be  possible  for 
either  of  them  to  be  the  seat  of  disease  and  not  involve 
the  space. 

The  hypothenar  space  would  become  involved  in  an 
osteomyelitis  of  the  fifth  metacarpal. 

The  subaponeurotic  space  would  become  involved  by 
an  osteomyelitis  of  the  middle  and  ring  finger  meta- 
carpals particularly,  and  at  times  from  the  little  and 
index  metacarpals.  Lymphatic  abscesses  along  the 
deep  dorsal  vessels  would  also  lie  under  this  sheet  of 
tissue. 

The  dorsal  subcutaneous  space  communicates  freely 
with  the  fingers  and  the  thumb. 

The  lumbrical  spaces  would  be  involved  by  extension 
from  a  tendon  sheath  infection  from  either  side  and 
from  an  infection  at  the  web  between  the  fingers  or 
a  "collar-button"  abscess. 


184  PATHOGEN  ESI  S 


The  tendon  sheaths  may  be  involved  by  direct  injury 
or  by  lymphatic  extension  from  slight  injuries  upon  the 
volar  surface  of  the  fingers  or  thumb. 

Extensions  may  occur  from  one  sheath  to  another 
by  extension  through  a  lumbrical  space  or  other 
fascial  space  abscess. 

The  extension  from  the  little  finger  to  the  ulnar 
bursa  and  then  to  the  radial  bursa,  or  the  sheath  of 
the  flexor  longus  pollicis,  is  well  known  and  frequently 
met  with  by  the  surgeon. 

Extension  from  one  fascial  space  to  another  may 
be  seen.  Extension  from  the  lumbrical  spaces  to  the 
middle  palmar  and  vice  versa  occurs  very  easily,  while 
extension  between  the  middle  palmar  and  thenar 
occurs  only  in  neglected  cases.  Extension  from  the 
lumbrical  space  to  the  loose  tissue  of  the  web  on  the 
dorsum  is  also  common,  but  extension  from  the  palmar 
spaces  to  the  dorsum  between  the  metacarpal  bones  is 
very  uncommon.  Extension  can  occur  from  the  middle 
palmar  space  to  the  deep  spaces  of  the  forearm,  but 
this  is  also  uncommon.  This  extension  is  nearly  always 
due  to  a  rupture  from  an  ulnar  or  radial  bursitis. 


CHAPTER    XII. 

THE  SPREAD  OF  INFECTION  FROM  ANY 
GIVEN  PRIMARY  FOCUS. 

THIS  will  be  discussed  under  three  heads — the  pos- 
sible spread  from  primary  foci  on  the  fingers,  from 
foci  on  the  palm,  from  foci  on  the  dorsum. 

THE  PROBABLE  EXTENSIONS  FROM  PRIMARY  FOCI  ON  THE 

FINGERS. 

THE  SPREAD  OF  INFECTION  INVOLVING  THE  INDEX  FINGER. 

The  index  finger  having  received  a  severe  injury, 
causing  a  deep  infection,  we  admit  that  the  infection 
can  spread  by  three  methods:  (a)  Lymphatic;  (b) 
fascial;  (c)  through  the  synovial  sheath.  The  subject  of 
lymphatic  extension  is  discussed  in  Chapter  XXI. 

FASCIAL  SPACE  EXTENSION.— The  extension  by  the 
fascial  spaces  is  easy  to  follow  when  we  study  the 
series  of  cross-sections  (Figs.  65  to  72).  By  studying 
these  we  see  there  is  loose  connective  tissue  surround- 
ing the  phalanges  in  which  it  could  spread  with  ease. 
Upon  the  dorsum  it  might  go  up  into  the  subcutaneous 
tissue  in  the  back  of  the  hand,  internally,  it  would 
come  to  lie  in  the  cellular  spaces  at  the  web  between 
the  index  and  middle  fingers,  and  could  even  spread 
along  the  lumbrical  muscle  of  the  middle  finger  into 
the  palm,  and  thus  invade  the  middle  palmar  space. 
This  latter  extension,  however,  would  be  more  likely 
to  occur  in  a  deep  inflammation  involving  the  proximal 
phalanx  of  the  middle  finger,  if  at  all ;  since,  as  a  general 
rule,  the  pus  would  come  to  the  surface  before  extending 
along  the  lumbrical  canal. 


186    INFECTION  FROM  ANY  GIVEN  PRIMARY  FOCUS 

Upon  the  radial  side  of  the  index  finger  there  would 
be  still  less  likelihood  of  the  pus  entering  the  lumbri- 

FIG.  65 


IDSA5 


SCS 


. 

Cross-section  No.  I. — DSAS,  dorsal  subaponeurotic  space;  DV  and  N, 
digital  vessels  and  nerves;  ECT,  extensor  communis  tendon;  FT,  flexor 
tendon;  PP,  proximal  phalanx;  SCS,  subcutaneous  space;  55,  synovial 
sheath.  The  tendon  sheaths  are  shown  in  red. 

FIG.  66 


Cross-section  No.  II. — Through  epiphysis  of  proximal  phalanx.  DSAS, 
dorsal  subaponeurotic  space;  DSCS,  dorsal  subcutaneous  space;  DV  and  N, 
digital  vessels  and  nerves;  ECT,  extensor  communis  tendon;  EPP,  epiphysis 
proximal  phalanx;  FT,  flexor  tendon;  IM,  interossei  muscles;  LM,  lumbrical 
muscle;  SS,  synovial  sheath.  The  tendon  sheaths  are  shown  in  red. 

cal  canal  in  preference  to  coming  to  the  surface,  since 
this  canal  is  not  so  well  marked.     Of  course,  it  could 


INFECTION  INVOLVING  THE  INDEX  FINGER     187 

not  extend  upon  the  volar  side  into  the  palm,  because 
there  is  no  connecting  space  (see  cross-sections  66  and 
68).  Again,  we  note  that  if  the  pus  were  under  the 
dorsal  aponeurosis  of  the  proximal  phalanx,  it  would  be 
limited  to  this  area,  since  it  is  a  closed  space  and  does 
not  communicate  with  the  subaponeurotic  foyer  upon 
the  dorsum  of  the  hand.  Thus,  we  see  that  while  it  is 
possible  for  the  thenar  space  to  become  infected  by 
fascial-space  extension  from  the  index  finger,  it  is  not 
probable.  However,  a  metacarpophalangeal  arthritis 

FIG.  67 


Cross-section  No.  III. — Proximal  to  metacarpophalangeal  joint.  DSAS, 
dorsal  subaponeurotic  space;  DSCS,  dorsal  subcutaneous  space;  DT,  dense 
fibrous  tissue;  DV  and  N,  digital  vessels  and  nerves;  ECT,  extensor  com- 
munis  tendon;  FT,  flexor  tendon;  IM,  interossei  muscles;  LM,  lumbrical 
muscle;  MB,  metacarpal  bone;  SB,  sesamoid  bone;  SS,  synovial  sheath. 
Tendon  sheaths  are  shown  in  red  and  the  boundaries  of  the  lumbrical  spaces 
in  blue. 

may  develop  with  destruction  of  the  bone  and  liga- 
ments. This  extension  then  becomes  not  only  possible 
but  probable,  since  the  metacarpal  bone  of  the  index 
finger  lies  in  juxtaposition  to  the  thenar  space,  sep- 
arated, however,  in  part,  by  the  adductor  transversus. 
Pus  would  probably  first  enter  the  space  between  the 


188    INFECTION  FROM  ANY  GIVEN  PRIMARY  FOCUS 

adductor  transversus  and  the  first  dorsal  interosseous, 
then  pass  into  the  thenar  space. 

The  question  now  arises,  however,  should  the  pus 
lie  either  primarily  or  secondarily  in  the  subcutaneous 
tissue  upon  the  dorsum  of  the  hand  in  the  region  of 
the  index  metacarpal,  could  it  spread  around  the  radial 
border  of  the  index  metacarpal  into  the  thenar  space? 

FIG.  68 


Cross-section  No.  IV. — Two  cm.  proximal  to  joint.  APT,  abductor  trans- 
versus pollicis;  DSAS,  dorsal  subaponeurotic  space;  DSCS,  dorsal  subcu- 
taneous space;  DT,  dense  fibrous  tissue;  ECT,  extensor  communis  tendon; 
FLP,  flexor  longus  pollicis  in  its  synovial  sheath;  FT,  flexor  tendon; 
IM,  interossei  muscles;  LM,  lumbrical  muscle;  M,  metacarpal  bone;  MFC, 
middle  flexion  crease;  MPS;  middle  palmar  space;  RI,  radialis  indicis; 
SS,  synovial  sheath;  TS,  thenar  space.  The  tendon  sheaths  are  shown 
in  red  and  the  lumbrical  spaces  in  blue.  Note  the  beginning  of  the  middle 
palmar  space. 

Again,  should  it  lie  in  the  subcutaneous  tissue  between 
the  index  and  thumb  metacarpals,  could  it  pass  under 
the  web  into  that  space?  The  study  of  the  cross- 
sections  (Figs.  69  and  70)  as  well  as  the  experimental 
injections  (Nos.  39  and  40)  seem  to  show  that  this 
is  not  probable.  Clinical  evidence  can  be  adduced 
to  corroborate  this.  The  pus  would  rather  come  to 


INFECTION  INVOLVING  THE  INDEX  FINGER     189 


the  surface  upon  the  dorsum.  The  subaponeurotic 
accumulations,  unless  complicated  by  an  osteomyelitis, 
would  also  follow  the  same  course.  (See  experiments. 
Figs.  43  to  45.) 

FIG.  69 


D5C5       V    IM 


DIM       M 


D5A5        ECT 


Cross-section  No.  V. — 3^  cm.  proximal  to  joint.  A  TP,  adductor  trans- 
versus  pollicis;  BV,  bloodvessels;  DIM,  dorsal  interosseous  membrane; 
DSAS,  dorsal  subaponeurotic  space;  DSCS,  dorsal  subcutaneous  space; 
ECT,  extensor  communis  tendon;  FLP,  flexor  longus  pollicis  in  its  synovial 
sheath;  FT,  flexor  tendon;  HM,  hypothenar  muscles  with  intermuscular 
spaces;  IM,  interossei  muscles;  IS,  space  between  adductor  transversus 
and  first  dorsal  interosseous;  IV,  interosseous  vessels  and  nerve;  LM, 
lumbrical  muscle;  M,  metacarpal  bone;  MPS,  middle  palmar  space;  N, 
nerves;  PIM,  palmar  interosseous  membrane;  55,  synovial  sheath;  TS, 
thenar  space;  UB,  ulnar  bursa;  £77  and  N,  ulnar  vessels  and  nerve;  V,  vein. 
The  tendon  sheaths  are  shown  in  red  (ulnar  bursa  and  radial  bursa).  The 
outline  of  the  middle  palmar  and  thenar  spaces  are  shown  in  blue. 

SYNOVIAL  SHEATH  EXTENSION. — We  now  come  to 
the  third  method  of  extension — by  the  index  synovial 
sheath.  Let  us  suppose  that  the  synovial  sheath 
has  become  filled  with  pus  and  an  "extension  taken 


190    INFECTION  FROM  ANY  GIVEN  PRIMARY  FOCUS 

place  into  the  hand  along  this  sheath.  Here  the 
anatomical,  experimental,  and  clinical  evidence  is 
clear.  (See  cross-sections,  Figs.  69  and  70;  Experiments 
8,  9,  27,  and  35;  Case  X.)  Having  ruptured  from  the 
proximal  end  of  the  sheath,  where  it  is  very  thin 

FIG.  70 


Cross-section  No.  VI. — Through  distal  part  of  thenar  area.  A  TP,  adductor 
transversus  pollicis;  DIA,  dorsalis  indicis  artery;  DP  A,  deep  palmar  arch; 
DSAS,  dorsal  subaponeurotic  space;  DSCS,  dorsal  subcutaneous  space; 
ECT,  extensor  flexor  tendon;  HM,  hypothenar  muscles  with  intermuscular 
spaces;  ITS,  indefinite  thenar  spaces;  IM,  interossei  muscles;  LM,  lum- 
brical  muscle;  M,  metacarpal  bone;  MA  and  N,  median  artery  and  nerve; 
MPS,  middle  palmar  space;  PF,  palmar  fascia;  PIM,  palmar  interosseous 
membrane;  TM,  thenar  muscles;  TMF,  tendon  of  middle  finger;  TS, 
thenar  space;  UV  and  N,  ulnar  vessels  and  nerves.  The  ulnar  bursa,  radial 
bursa,  and  an  intermediate  tendon  sheath  are  shown  in  red.  The  boundaries 
the  middle  palmar  and  thenar  spaces  are  shown  in  blue. 

generally,  the  pus  would  lie  in  the  loose  connective 
tissue  which  surrounds  this  tendon  and  the  lumbrical 
muscle.  After  a  short  time,  as  the  infection  persisted, 
or  the  accumulation  of  pus  grew,  it  would  follow  the 
lines  of  least  resistance,  and  run  along  the  lumbrical 
muscle  toward .  the  radial  side  of  the  index  finger 
(Experiment  8,  Fig.  73),  and,  being  limited  here, 


INFECTION  INVOLVING  THE  INDEX  FINGER     191 

would  then  rupture  through  the  thin  sheet  of  fascia, 
separating  this  tissue  from   the   thenar  space   (cross- 

FIG.  71 


Cross-section  No.  VII. — DSAS,  dorsal  subaponeurotic  space;  DSCS, 
dorsal  subcutaneous  space;  ECT,  extensor  communis  tendon;  FLP,  flexor 
longus  pollicis  in  its  synovial  sheath;  FT,  flexor  tendon;  HM,  hypothenar 
muscles  with  intermuscular  spaces;  75,  space  between  adductor  transversus 
and  first  dorsal  interosseous;  M,  metacarpal  bone;  MN  and  V,  median  nerve 
and  vessels;  MPS,  middle  palmar  space;  RA,  radial  artery;  SS,  synovial 
sheath;  TM,  thenar  muscles;  TS,  thenar  space;  UB,  ulnar  bursa;  UV  and  N, 
ulnar  vessels  and  nerve.  The  ulnar  and  radial  bursae  and  the  intermediate 
tendon  sheaths  are  outlined  in  red  and  the  middle  palmar  and  thenar  spaces 
in  blue. 

sections,  Figs.  69  and  70),  and  thus  become  a  thenar 
space  infection.  (For  tendon  sheath  extensions  see 
also  Chapters  IX  and  XI.) 

The  following  case  corroborates  these  deductions: 

CASE  X. — Seen  in  the  service  of  Prof.  F.  A.  Besley  at 
the  Post-Graduate  Hospital. 


192    INFECTION  FROM  ANY  GIVEN  PRIMARY  FOCUS 

Diagnosis:  Infected  wound  of  index  finger,  tenosyno- 
vitis  of  index  tendon,  infection  of  thenar  space,  ultimate 
amputation  of  finger. 

FIG.  72 


ECU 


Cross-section  No.  VIII. — DSCS,  dorsal  subcutaneous  space;  EC,  extensor 
communis;  ECRB,  extensor  carpi  radialis  brevior;  ECRL,  extensor  carpi 
radialis  longior;  ECU,  extensor  carpi  ulnaris;  EMD,  extensor  minimi  digiti; 
EPTP,  extensor  primi  internodii  pollicis;  ESIP,  extensor  secundi  internodii 
pollicis;  FLP,  flexor  longus  pollicis  in  its  synovial  sheath;  HM,  hypothenar 
muscles  with  intermuscular  spaces;  MN  and  V,  median  nerve  and  vessels; 
PL,  palmaris  longus ;  PMPS,  prolongation  of  middle  palmar  space ;  R  V  and 
N,  radial  vessels  and  nerves;  55,  synovial  sheaths;  TM,  thenar  muscles;  UB, 
ulnar  bursa;  UV  and  N,  ulnar  vessels  and.  nerve.  The  ulnar  bursa,  radial 
bursa,  and  intermediate  sheaths  are  shown  in  red.  The  small  prolongation 
of  the  middle  palmar  and  thenar  spaces  in  blue. 


September  2,  1904.  T.  W.  Ten  days  before  coming 
to  the  hospital  the  patient  cut  his  finger  just  above  the 
knuckle-joint  on  a  tin  can;  wound  slightly  to  radial  side 
of  dorsum.  This  became  infected,  and  the  patient  con- 
sulted a  physician,  who  opened  the  wound  and  passed  a 


INFECTION  INVOLVING  THE  INDEX  FINGER     193 

drainage  tube  through  and  across  the  dorsum,  coming  out 
between  the  index  and  middle  fingers.  Upon  examination 
the  finger  was  seen  to  be  much  swollen,  as  was  the  entire 
hand,  particularly  the  dorsum.  Several  openings  appeared 
about  the  proximal  phalanx.  A  probe  into  one  of  these 
found  rough  bone  and  easily  entered  the  knuckle-joint. 
The  entire  finger  and  hand  were  slightly  tender,  but 
marked  and  conspicuous  tenderness  was  elicited  over  the 

FIG.  73 


Schematic  drawing  made  from  a  dissection  of  a  hand  injected  along  the 
tendon  sheath  of  the  index  finger.  Mass  filled  thenar  space  and  extended 
around  to  the  dorsum  underneath  adductor  transversus  and  also  along 
lumbrical  muscle. 

site  of  the  tendon  sheath,  and  sharply  limited  by  it,  being 
most  acute  at  the  proximal  end,  over  the  metacarpophalan- 
geal  articulation.  Flexion  of  finger  did  not  increase  pain; 
extension  of  index  finger  caused  marked  pain  through 
finger,  but  most  sharply  noted  by  patient  at  proximal 
end  of  sheath.  Extension  of  other  fingers  caused  little 
increase  of  pain;  no  particular  pain  on  dorsum  of  finger 
where  cuts  were  found.  Temperature,  101°;  pulse,  92. 
13 


194    INFECTION  FROM  ANY  GIVEN  PRIMARY  FOCUS 

Infection  of  foot  present  also,  as  well  as  small  boil  on 
opposite  shoulder.  Epitrochlear  and  axillary  glands 
swollen  out  of  proportion  to  those  in  left  arm.  (Patient's 
resistance  is  evidently  far  below  par).  Systemic  symptoms 
marked.  Neutrophilia,  94  per  cent. 

Clinical  Diagnosis :  Infected  wound  of  hand ;  probably 
staphylococcus ;  infected  index  tendon  sheath ;  extension  to 
glands  of  axilla  and  elbow  and,  in  addition,  infection  of 
skin  on  shoulder  and  in  foot.  Etiology  of  latter  unknown 
— possibly  pyemic  from  hand;  infected  knuckle-joint. 

Prognosis:     Will  probably  lose  finger. 

Operation:  Tendon  sheath  opened  from  end  to  end. 
Pus  in  moderate  amount  evacuated.  Dorsal  openings 
previously  present  enlarged.  Hot  boric  dressings.  Foot 
opened  and  drained.  Temperature  ran  99?  to  101°  every 
day. 

September  9.  Finger  shows  fluctuation  on  dorsum  of 
hand  just  proximal  to  index  finger  and  ulnarly.  Incision 
and  drainage.  Finger  not  so  painful;  flexion  about  same. 
Not  so  tender;  no  special  swelling  in  palm  of  hand. 

September  12.  Infection  has  extended  to  thenar  emi- 
nence ;  tenderness  localized  to  this  area.  Swelling  marked ; 
palm  not  involved. 

Operation:  Inserted  forceps  into  cut  on  dorsum  made 
September  9;  forceps  fell  into  direct  communication  with 
volar  surface  of  thenar  eminence;  opened  here;  pushed 
forceps  then  from  volar  surface  through  to  dorsum  be- 
tween first  and  second  metacarpals ;  forceps  passed  through 
dorsal  skin  with  little  or  no  resistance;  drainage  inserted. 

September  15.  Subcutaneous  abscess  has  developed 
in  radial  region  of  forearm  above  wrist  and  above  elbow, 
and  over  brachial  vessels;  incised  and  drained.  White 
blood  cells,  18,000. 

September  24.     Temperature,  99°  to  101°. 

October  14.  Temperature  has  been  running  99°  to 
1 00°  for  last  two  weeks;  index  finger  swollen  to  four  times 
its  normal  size;  blue,  and  evidently  there  is  an  osteo- 
myelitis of  the  proximal  phalanx,  and  a  suppurative 
arthritis  of  the  metacarpophalangeal  joint. 

Operation:  Index  finger  and  head  of  metacarpal  bone 
amputated ;  drainage. 

October  20.      Condition  of  hand   much  better. 


INFECTION  INVOLVING  THE  THUMB  195 

Following  this  the  patient  improved  rapidly;  dis- 
charged. 

November  3,  1904.  Small  area  of  granulation  tissue 
over  amputated  area;  moves  thumb  and  three  fingers 
three-fourths  of  normal;  wrist-joint  same;  function  of  all 
will  ultimately  be  restored. 


THE  SPREAD  OF  INFECTION  INVOLVING  THE  THUMB. 

Infection  of  the  thumb  would  at  first  glance  seem  to 
offer  the  most  favorable  course  for  pus  to  extend  into 
the  thenar  space.  But  let  us  consider  for  a  moment. 
Lymphatic  extension  does  offer  some  chance,  if  the 
infection  be  deep  and  upon  the  ulnar  side,  as  will  be 
pointed  out  (Chapter  XX,  and  Fig.  no).  Upon  the 
other  parts,  however,  the  tendency  would  be  for  the 
pus  to  be  carried  away  from  the  space. 

The  synovial  sheath  of  the  flexor  longus  pollicis  lies 
some  distance  from  the  space,  and  hence  pus  would 
tend  to  come  to  the  surface  if  the  sheath  ruptured  in 
its  course.  It  can  be  seen,  however,  that  if  the  sheath 
ruptured  in  its  distal  part,  and  the  infection  thus 
became  an  infection  of  the  connective-tissue  spaces, 
it  could  spread  along  the  ulnar  side  of  the  thumb,  and 
by  considerable  destruction  of  connective  tissue  come 
to  lie  upon  the  origin  of  the  adductor  transversus, 
and  thus  invade  the  space.  In  the  majority  of  cases, 
however,  the  pus  would  rupture  from  the  sheath  into 
the  forearm.  (For  further  discussion  of  tendon-sheath 
extensions,  see  Chapters  IX  and  XIV.) 

Should  the  infection  be  upon  the  back  of  the  thumb, 
the  pus  would  extend  more  easily  into  the  dorsal  sub- 
cutaneous tissue  of  the  thenar  area,  while,  in  all 
probability,  upon  its  radial  side  it  would  point  upon 
the  surface. 


196    INFECTION  FROM  ANY  GIVEN  PRIMARY  FOCUS 


THE  SPREAD  OF  INFECTION  INVOLVING  THE  MIDDLE  FINGER. 

Here  the  finger,  lying  as  it  does  in  the  dividing  line 
between  the  thenar  and  middle  palmar  spaces,  becomes 
an  extremely  interesting  subject  of  study.  The  lym- 
phatic extension  has  already  been  touched  upon  and 
will  be  discussed  further  in  Chapters  XX  to  XXIV. 

Extension  from  the  synovial  sheath  at  its  proximal 
end  gives  positive  results  experimentally  (Experiments 

FIG.  74 


Schematic  drawing  made  from  a  dissection  of  a  hand  injected  from  the 
tendon  sheath  of  the  middle  finger.  The  mass  filled  the  middle  palmar  space 
and  extended  along  the  two  lumbricals. 

I  and  2),  since  in  every  case  the  mass  extended  into 
the  middle  palmar  space  after  rupturing  through  the 
indefinite  connective  tissue,  separating  it  from  the 
space,  as  already  described  under  the  index  finger 
discussion.  It  is  to  be  borne  in  mind,  however,  that 
the  lumbrical  muscle  joining  this  tendon  comes  back 
to  pass  under  the  transverse  ligament,  between  the 


INFECTION  INVOLVING  THE  RING  FINGER       197 

index  and  middle  fingers,  and  that  while  the  tissue 
intervening  between  this  muscle  and  the  thenar  space 
is  firm,  and  experimental  injections  have  failed  to 
rupture  through,  yet,  anatomically,  it  would  seem 
to  be  possible  in  some  cases.  Clinical  evidence  shows 
that  while  it  does  occur  this  extension  is  rare.  For  a 
complete  discussion  of  the  extensions  from  the  tendon 
sheaths,  see  Chapters  IX  and  XIV.  Should  the  in- 
fection be  a  deep-seated  accumulation  of  pus  in  the 
cellular  tissue  upon  the  dorsum  it  could  spread  sub- 
cutaneously  upon  the  back  of  the  hand ;  upon  the  radial 
side  it  would  pass  exceptionally  along  the  lumbrical 
muscle  into  the  middle  palmar  space,  with  the  pos- 
sibility of  invading  the  thenar  space,  as  above  noted; 
upon  the  ulnar  side,  if  it  should  spread  along  the 
lumbrical  muscle,  it  would  go  into  the  middle  palmar 
space  (Experiments  26  A,  and  26  B}. 

Subaponeurotic  infection  would  be  limited  to  the 
phalanx,  while  osteomyelitis,  involving  the  metacarpal 
bone,  would  tend  to  invade  the  middle  palmar  space 
in  front  and  the  subaponeurotic  on  the  back. 

THE  SPREAD   OF   INFECTION  INVOLVING  THE   RING  FINGER. 

Here  there  is  little  doubt  about  the  relatioa  between 
this  finger  and  the  middle  palmar  space.  The  exten- 
sion by  the  dorsal  subcutaneous  tissue  may  be  in  any 
direction.  The  connective-tissue  spaces  at  either 
side  of  the  finger  and  in  the  web  of  the  infected  hand 
allow  the  pus  to  spread  through  the  fibrous  canal  sur- 
rounding the  lumbrical  muscles  and  lead  into  the 
palmar  space.  (See  Experiments  26  A  and  26  B,  and  Fig. 
21.)  In  making  this  deduction  it  should  be  emphasized 
again  that  in  a  majority  of  cases  pus  would  be  evacu- 
ated on  the  surface  before  it  would  burrow  through 
this  canal.  Hence  it  is  only  in  neglected  cases  that 


198    INFECTION  FROM  ANY  GIVEN  PRIMARY  FOCUS 

this  complication  would  ensue,  unless  extension  had 
taken  place  by  the  lymphatic  channels  which  pass 
through  these  same  canals. 

Suppuration  extending  from  the  synovial  sheath 
would  enter  the  middle  palmar  space.  (See  Experiments 
3,  4,  1 8,  19,  and  20;  cross-sections,  Figs.  69  and  70.) 
Primarily,  of  course,  it  would  lie  in  the  loose  connective- 
tissue  superficial  to  the  space,  spread  down  along  the 


FIG.  75 


Schematic  drawing'made  from  a  dissection  of  a  hand  injected  along  the 
tendon  sheath  of  the  ring  finger.  The  mass  filled  the  middle  palmar  space, 
with  extension  along  the  lumbrical  muscle. 

lumbrical  muscles  (Fig.  36),  especially  of  the  little, 
ring,  and  middle  fingers,  and  then,  destroying  the  thin 
roof  of  the  space,  would  involve  the  entire  middle 
palmar  space  (Fig.  75).  (For  a  complete  discussion  of 
tendon-sheath  extensions,  see  Chapters  IX  and  XIV.) 
Arthritis  of  the  metacarpophalangeal  joint,  with 
osteomyelitis  of  the  diaphysis  of  the  metacarpal, 


INFECTION  SPREADING  FROM  LITTLE  FINGER     199 

could  also  infect  this  space  as  well  as  the  subaponeu- 
rotic  on  the  dorsum  (Case  VIII). 

(The    lymphatic    extension    will    be    discussed    in 
Chapters  XX  and  XXI.) 

FIG.  76 


Schematic  drawing  made  from  a  dissection  of  a  hand  in  which  the  mass 
was  injected  along  the  tendon  sheath  of  the  little  finger;  closure  at  the  upper 
end  of  the  annular  ligament  of  the  ulnar  bursa  allowed  rupture  from  the 
ulnar  bursa,  the  mass  filling  the  middle  palmar  space,  with  extension  along 
one  lumbrical  muscle. 


INFECTION  SPREADING  FROM  THE  LITTLE  FINGER. 

Here  the  lymphatic  channels  and  connective-tissue 
spaces  upon  the  inner  side  of  the  finger  could  lead  into 
the  middle  palmar  space,  although  such  extension  is 
uncommon.  On  the  outer  and  dorsal  side  they  would 
tend  to  lead  into  the  subcutaneous  tissue  externally. 

The  synovial  sheath,  if  continuous  with  the  ulnar 
bursa,  would  probably  rupture  earliest  in  the  forearm. 
(See  x-ray  plate,  Fig.  39.)  (For  a  discussion  of  this,  see 
Chapters  IX  and  XIV.)  If  it  did  rupture  in  the  hand, 


200    INFECTION  FROM  ANY  GIVEN  PRIMARY  FOCUS 

or  if  the  synovial  sheath  of  the  finger  were  shut  off 
from  the  ulnar  bursa,  and  the  finger  sheath  ruptured, 
it  would  tend  to  involve  the  middle  palmar  space 
(See  Experiments  5  and  6,  Fig.  76.)  It  might  be  men- 
tioned here  that  Chevalet  and  Dolbeau  maintain  that 
a  rupture  of  the  sheath  is  not  necessary  to  extension 
but  that  this  can  take  place  from  the  sheath  by  lym- 
phatic extension,  and  they  adduce  a  postmortem 
examination  in  support  of  their  contention.  This, 
however,  is  an  academic  question,  since  the  same  space 
would  be  involved  by  the  extension,  and  the  clinical 
findings  would  be  identical.  (For  a  complete  discus- 
sion of  the  tendon-sheath  extensions,  see  Chapters 
IX  and  XIV.) 

If  an  osteomyelitis  of  the  fifth  metacarpal  be  present, 
the  hypothenar  space  would  be  involved  upon  the 
volar  surface  and  the  subcutaneous  tissue  dorsally. 
(See  cross-sections,  Figs.  69  and  70.) 

INFECTIONS  BEGINNING  IN  THE  PALM  AND  DORSUM. 

When  a  primary  focus  appears  upon  the  palm,  if  it 
is  a  punctured  wound,  the  abscess  may  develop  in  any 
of  the  pockets  I  have  described,  if  implanted  there 
under  the  palmar  fascia.  If  in  the  superficial  thenar 
or  hypothenar  area,  they  may  develop  local  abscesses 
without  entering  the  palmar  or  thenar  spaces.  If  the 
infection  develops  at  the  distal  part  of  the  palm  in  the 
subcutaneous  tissue  or  in  the  lumbrical  space,  i.  e., 
a  "frog  felon,"  "collar-button"  abscess  (see  Chapter 
IV),  and  if  extension  occurs  it  will  generally  be  to  the 
dorsum  between  the  bases  of  the  fingers,  although 
occasionally  proximally  along  the  lumbrical  canals  into 
the  middle  palmar  space,  if  between  the  little  and 
ring  fingers — or  into  the  thenar  space  if  between  the 
middle  and  index  fingers.  In  the  central  part  of  the 


L 

palm  it  is  not  possible  for  large  abscesses  to  develop 
between  the  skin  and  the  palmar  fascia,  owing  to 
their  intimate  association. 

Lymphatic  infections  in  the  central  part  of  the 
palm  may  involve  the  deeper  part  of  the  hand  (Fig. 
i  \2).  At  the  sides  the  infection  pursues  the  shortest 
course  to  the  back  of  the  hand,  where  abscesses  may 
develop  subcutaneously.  At  the  proximal  end  of  the 
palm  secondary  lymphatic  abscesses  may  develop 
subcutaneously  above  the  anterior  annular  ligament. 
(See  Chapter  XIV.) 

Middle  palmar  and  thenar-space  abscesses  are 
generally  secondary  and  are  discussed  elsewhere  in 
detail. 

When  the  primary  focus  develops  upon  the  dorsum, 
if  it  be  a  localized  abscess  it  will  be  either  in  the  sub- 
cutaneous or  subaponeurotic  spaces.  If  extension  takes 
place  by  contiguity  or  lymphatic  channels,  the  second- 
ary abscesses  lie  upon  the  dorsum  of  the  forearm  or  the 
glandular  areas  at  the  elbow  and  axilla. 


Infection  may  spread  in  one  of  three  ways;  by 
a  lymphatic  canal,  by  a  fascial  space,  or  through  a 
synovial  sheath. 

If  the  infection  in  the  index  finger  spreads  by  the 
fascial  spaces,  the  pus  will  lie  in  the  connective  tissue 
at  the  web  of  the  index  and  middle  finger,  whence  it 
may  spread  along  the  lumbrical  muscle  into  the  palm. 

In  any  other  part,  the  pus  will  lie  underneath  the 
skin  and  will  soon  come  to  the  surface. 

The  proximal  interphalangeal  joint  will  be  involved 
more  often  than  the  metacarpophalangeal  joint. 

When  the  pus  extends  by  way  of  the  synovial  sheath 
it  may  spread  to  the  thenar  space;  either  by  direct 


202    INFECTION  FROM  KflFF  GIVEN  PRIMARY  FOCUS 

-iT/^lOr;  I  cVJ   T^ 

^upture  into  the  space  or 'by  an  intermediate  involve- 
ment that  embraces  the  space  on  either  side;  less  often 
it  will  involve  the  proximal  interphalangeal  joint  or 
come  to  the  surface. 

Infection  involving  the  thumb,  if  it  spreads  by  the 
fascial  space,  will  readily  come  to  the  surface.  If  by 
the  synovial  sheath,  it  will  rupture  into  the  forearm 
or  possibly  into  the  thenar  space. 

If  the  middle  finger  be  involved  and  the  pus  spreads 
by  the  fascial  space,  it  will  come  to  the  surface  or  lie 
in  the  connective-tissue  space  at  the  web,  whence  it  may 
involve  the  middle  palmar  or  thenar  space  by  way  of 
the  lumbrical  canal.  It  will  not  generally  come  to  the 
surface,  however.  If  it  spreads  by  way  of  the  tendon 
sheath,  it  will  ordinarily  involve  the  middle  palmar 
space  but  may  involve  the  thenar  space.  In  the 
latter  instance,  the  course  is  by  the  intermediate 
channels  along  the  lumbrical  space  between  the  index 
and  middle  fingers.  In  the  former  case  it  is  by  way 
of  the  lumbrical  canal  between  the  middle  and  ring 
finger.  The  proximal  interphalangeal  joint  will  at 
times  become  involved. 

If  the  pus  spreads  along  the  ring  finger  by  way  of 
the  fascial  space,  it  will  be  liable  to  come  to  the  surface 
or  involve  the  connective-tissue  space  on  either  side  of 
the  web,  where  it  will  ordinarily  rupture  externally  but 
may  pass  along  either  lumbrical  canal  into  the  middle 
palmar  space. 

If  the  tendon  sheath  be  involved,  pus  will  invade 
the  middle  palmar  space  either  directly  or  by  rupture 
and  extension  along  the  lumbrical  canal  on  either  side. 
It  may  involve  the  interphalangeal  joint  or  come  to 
the  surface. 

If  infection  spreads  along  the  little  finger  by  way  of 
the  fascial  space,  the  pus  will  either  come  to  the  sur- 
face or  lie  in  the  connective- tissue  space  of  the  web 


RESUME  203 

between  the  ring  and  little  finger,  from  whence  it  will 
probably  come  to  the  surface  but  may  spread  along 
the  lumbrical  canal  into  the  middle  palmar  space. 

If  the  pus  spreads  by  the  tendon  sheath  it  will 
ordinarily  extend  into  the  ulnar  bursa  and  from  thence 
may  involve  the  tissue  in  the  forearm  underneath  the 
flexor  profundus  or  rupture  into  the  middle  palmar 
space.  It  generally  involves  the  radial  bursa  after  a 
day  or  two.  It  may  be  confined  in  the  tendon  sheath 
of  the  little  finger  and  rupture  into  the  lumbrical 
space  between  the  little  finger  and  ring  finger  and 
thence  involve  the  middle  palmar  space. 

If  pus  spreads  from  the  palm  and  is  superficial  to 
the  palmar  fascia,  it  will  develop  small  abscesses  which 
will  rupture  quickly.  If  in  the  distal  part  of  the  palm 
in  the  connective  tissue  at  the  web  or  in  the  lumbrical 
space,  it  will  either  come  to  the  surface  at  the  web  or 
enter  the  lumbrical  canal  and  pass  into  either  the 
middle  palmar  or  thenar  space  varying  with  the  area 
involved. 

If  in  the  middle  palmar  space,  the  pus  will  extend 
into  the  lumbrical  canal  to  the  web  and  possibly  rupture 
through  the  intervening  tissue  into  the  thenar  space. 

Thenar  space  abscesses  will  ordinarily  come  to  the 
surface  on  the  dorsum,  between  the  thumb  and  index 
finger,  or  may  rupture  into  the  middle  palmar  space. 

If  in  the  hypothenar  space,  the  pus  will  ordinarily 
come  to  the  surface  upon  the  dorsum.  If  under- 
neath the  skin  of  the  dorsum  it  will  readily  rupture 
externally,  and  if  in  the  subaponeurotic  space,  it  will 
point  laterally  or  distally  at  the  edge  of  the  fascial 
sheath. 


CHAPTER    XIII. 

PATHOLOGY  OF  TENDON  SHEATH  AND 
FASCIAL-SPACE  ABSCESSES. 

THE  discussion  is  here  limited  to  changes  in  the 
tendons,  tendon  sheaths,  and  fascial  spaces.  The 
pathology  of  bone  changes,  arthritis,  and  secondary 
sequelae  in  the  hand  and  forearm  will  be  taken  up 
later. 

A  classification  of  the  changes  incident  to  teno- 
synovitis  may  be  made  as  follows: 

Primary:  A.  Changes  while  the  infection  is  limited 
to  the  sac:  (i)  Contents  of  sac,  serum,  tendon.  (2) 
Wall  of  sac.  (3)  Circulation,  lymphatics  with  edema. 

B.  When  rupture  of  the  sac  occurs:  (i)  Involve- 
ment of  the  fascial  spaces,  (a)  hand,  (b)  forearm.  (2) 
Involvement  of  the  nerves.  (3)  Involvement  of  joints. 
(4)  Involvement  of  bones. 

Secondary:  (i)  Tendon  adhesions.  (2)  Ankylosis  of 
joints.  (3)  Persistent  edema  and  hyperplasia  of  cellular 
tissue;  scar  contraction  with  subsequent  atrophy.  (4) 
Chronic  osteomyelitis. 

The  changes  occurring  in  the  section  under  "primary 
B"  will  be  discussed  under  fascial-space  abscesses 
following,  and  the  "secondary"  changes  will  be  dis- 
cussed in  detail  in  later  chapters,  dealing  with  the 
complications  and  sequelae  of  infections  (see  Chapter 
XXVIII). 

THE  TENDON  SHEATH  PROPER. 

Anyone  who  has  had  occasion  to  open  the  acutely 
inflamed  tendon  sheath  has  been  surprised  at  the  rapid 


THE  TENDON  SHEATH  PROPER  205 

change  which  has  taken  place.  The  changes  are  com- 
parable to  a  pressure  necrosis,  but  whether  due  to  the 
great  toxicity  of  the  streptococcus  infection  or  the 
great  edema  about  and  the  effusion  into  the  sheath, 
shutting  off  the  blood  supply,  may  be  a  question. 

The  serum  in  the  sac  in  the  more  acute  cases  is  nor- 
mally scanty  in  amount  and  only  slightly  tinted.  The 
consistency  varies  from  a  slightly  slimy  fluid  to  a  thick 
pus.  While  in  the  more  acute  varieties  the  amount  may 
at  times  be  very  great,  it  soon  ruptures,  and  on  oper- 
ation we  may  find  little  or  much  in  the  sac ;  in  the  more 
chronic  type  we  frequently  find  a  large  amount  of 
thick,  creamy  pus,  even  though  rupture  has  ensued. 

The  wall  of  the  sac  is  congested  and  edematous  with 
the  exception  of  the  part  under  the  anterior  annular 
ligament  where  the  pressure  is  great.  Here  necrosis, 
not  alone  of  the  sheath,  but  also  of  the  tendons,  is 
prone  to  occur.  While  we  may  find  the  synovial  wall 
clear  and  unchanged,  we  generally  find  it  cloudy  with 
whitish-yellow  spots  of  beginning  necrosis,  or  we  may 
find  even  early  the  entire  wall  seminecrotic.  Even  in 
these  cases  we  are  often  surprised  at  the  reparative 
possibilities  after  drainage  is  instituted. 

The  tendons  themselves  are  swollen,  but  retain  their 
glistening  synovial  covering  for  some  time.  At  the 
wrist,  however,  the  tendons  show  the  result  of  com- 
pression by  the  non-distensible  anterior  annular  liga- 
ment being  pale  and  compressed;  this  is  accentuated 
by  the  swelling  which  has  occurred  both  above  and 
below  the  ligament.  If  the  case  has  been  left  un- 
treated for  too  long  a  time,  the  tendons  lose  their 
glossy  covering  and,  becoming  necrotic,  are  extruded, 
looking  like  grayish  strings  of  connective  tissue. 

While  the  entire  hand  partakes  of  the  edema,  it  is 
in  the  finger  involved  that  the  most  extensive  and 
persistent  changes  occur.  Especially  in  the  neglected 


206     TENDON  SHEA  TH  A  ND  FA  SCI  A  L-SPA  CE  A  BSC  ESSES 

cases  do  we  see  a  most  extensive  exudation  of  inflam- 
matory elements  which  persist  for  weeks  after  the 
acute  process  has  subsided;  this  is  followed  by  an 
atrophy  of  the  entire  finger,  ankylosis  of  joints  and 
impaired  nerve  function,  which  aids  materially  in  pre- 
venting a  proper  use  of  the  finger  even  if  the  tendon 
is  not  destroyed.  The  adhesions  between  the  sheath 
and  the  tendon  combined  with  these  serious  sequelae 
make  an  almost  hopeless  prognosis  as  to  function  in 
the  neglected  cases. 

If  the  ulnar  bursa  has  been  involved,  the  ultimate 
result  is  the  characteristic  claw-hand. 

THE  FASCIAL-SPACE  ABSCESSES. 

In  discussing  the  essential  pathology  it  should  be 
remembered  that  we  are  restricting  ourselves  strictly 
to  that  phase  of  the  subject  having  a  relation  to  the 
anatomical  and  experimental  studies  preceding.  The 
pathology  of  acute  abscess  formation  in  connective 
tissue  is  too  well  known  to  merit  discussion  here. 
Moreover,  to  do  more  than  mention  the  arthritis  in 
the  wrist,  the  osteomyelitis  of  the  metacarpals,  and  the 
destruction  of  tissue  and  fistulous  sequelae  would  be 
out  of  place,  since  these  will  be  discussed  in  the  chap- 
ters dealing  especially  with  these  subjects.  We  should, 
however,  draw  attention  to  certain  consequences  of 
suppuration  in  the  individual  spaces. 

Let  us  ask  ourselves  what  would  be  the  after-results 
of  infection  of  the  middle  palmar  space  alone,  the 
tendon  sheath  not  being  opened.  We  shall  divide 
them  into  primary  and  secondary;  and  under  the 
caption  of  primary,  attention  should  be  drawn  to  the 
fact  that  the  scar  tissue  following  such  a  process  would 
involve  particularly  the  tendons  of  the  middle  and  ring 
fingers,  with  the  lumbrical  muscles  of  the  middle,  ring, 
and  little  fingers.  Consequently,  it  is  in  these  fingers 


THE  F ASCI AL-SP ACE  ABSCESSES  207 

that  we  would  expect  to  find  the  most  persistent 
adhesions  and  contraction;  and  it  is  in  consequence 
of  the  disturbed  circulation  in  the  bloodvessels  going 
to  these  fingers  that  long  persisting  edema  and  nutri- 
tional changes  occur,  augmented  somewhat,  probably, 
by  impaired  nerve  supply. 

Secondary  sequelae  are  noted  in  the  associated 
edema  and  changes  in  the  index  finger  and  the  thumb, 
and  while  these  are  severe,  they  are  not  of  such  high 
grade  as  in  others.  These  changes  are  most  marked 
in  the  index  finger,  and  are  due  to  the  juxtaposition 
of  the  tendons  and  the  intimate  relation  of  the  circu- 
lation. Moreover,  the  ulnar  bursa,  with  its  contained 
tendons,  is  adjacent  to  the  area  of  infection;  conse- 
quently, there  is  the  probability  of  a  low  grade  of 
inflammation  within.  Again,  the  correlation  of  move- 
ment between  the  tendons  determines  approximately 
the  same  position  for  the  index  finger  as  the  others. 
This  constant  position,  associated  with  an  effusion 
into  the  joints,  leads  to  adhesions  of  the  articular 
surfaces  in  all  the  fingers,  the  thumb  least  of  all,  since 
the  tendon  of  the  thumb  is  well  separated  from  the 
site  of  infection.  Should  the  process  extend  to  the 
thenar  area,  the  index  finger  would  then  be  in  the  same 
condition  as  the  other  fingers.  On  the  other  hand,  if 
the  infection  were  primary  in  the  thenar  space,  the 
most  disastrous  changes  would  ensue  in  that  finger, 
while  the  other  three  fingers  would  suffer  only  the 
secondary  changes,  but  fortunately  not  so  severe 
as  the  secondary  changes  were  in  the  thenar  space 
when  associated  with  palmar  infection.  This  is  owing 
not  alone  to  the  comparative  size  and  complexity  of 
the  areas,  but  also  to  the  fact  that  thenar  abscesses 
are  sooner  recognized  and  drained  more  perfectly; 
consequently  the  process  is  not  so  disastrous. 

Should     the     subaponeurotic     space    be     involved 


208     TENDON  SHEA  TH  A  ND  FA  SCI  A  L-SPA  CE  A  BSC ESSES 

primarily,  or  by  an  extension  from  the  palmar  space, 
secondary  adhesions  take  place,  and  the  whole  sheet 
becomes  more  or  less  immobile  as  a  consequence  of 
the  involvement  of  all  the  extensor  communis  tendons. 
Should  proper  treatment  be  resorted  to  even  after  a 
number  of  days,  all  of  these  changes  will  disappear 
and  a  perfectly  functionating  hand  be  assured. 


CHAPTER    XIV. 

THE  SYMPTOMS,  SIGNS,  AND  DIAGNOSIS 

OF  TENOSYNOVITIS  AND  FASCIAL- 

SPACE  ABSCESSES. 

THE    SYMPTOMS,    SIGNS,    AND    DIAGNOSIS   OF   ACUTE 
TENOSYNOVITIS. 

To  diagnosticate  the  onset  of  involvement  of  the 
tendon  sheaths  is  one  of  the  most  difficult  problems 
in  surgery;  and  yet  withal  one  of  the  most  important. 
I  know  of  no  place  where  calm  judgment  is  more  re- 
quired, since  the  symptoms  and  signs  are  all  of  degree. 
It  must  be  said,  however,  that  more  extensive  expe- 
rience has  taught  me  that  it  is  generally  better  to 
err  by  making  an  unnecessary  incision  than  by  failing 
to  operate  where  it  is  needed. 

The  three  cardinal  symptoms  and  signs  are: 

1.  Excessive  tenderness  over  the  course  of  the  sheath, 
limited  to  the  sheath.    This  symptom  is  by  all  odds  the 
most  important. 

2.  Flexion  of  the  finger. 

3.  Excruciating  pain  on  extending   the  finger,  most 
marked  at  the  proximal  end. 

These  symptoms  are  seen  to  be  only  a  difference  in 
degree  from  those  found  in  any  infection  of  the  hand, 
but  when  sought  for  in  an  intelligent  manner  there  is 
not  much  difficulty  in  differentiating  the  conditions. 

A   patient  applies   to   the   physician    with   what  is 

evidently   a   serious   infection.      If    there   has   been   a 

crushing  injury,  the  probability  of  an  infected  tendon 

sheath  is  great;  on  the  other  hand,  it  frequently  arises 

14 


210    SYMPTOMS,  SIGNS,  DIAGNOSIS  OF  TENOSYNOVITIS 

from  simple  cuts,  as,  for  instance,  a  slight  laceration 
from  a  tin  can  or  from  the  prick  of  a  needle,  or  there 
may  be  no  history  of  injury.  The  pain  has  increased 
in  severity  after  a  day  or  two.  The  systemic  symptoms 
of  infection  may  be  present.  The  finger  and  the  cor- 
responding side  of  the  hand  at  least  are  edematous. 
In  addition  to  the  tumefaction  in  the  infected  finger 
the  adjacent  digits  are  swollen.  The  back  of  the  hand 
particularly  is  edematous.  The  whole  hand  is  slightly 
tender  to  superficial  palpation.  The  fingers  are  all 
slightly  flexed.  Now,  how  shall  the  differential  diag- 
nosis be  made?  Press  deeply  and  firmly  in  all  parts 
of  the  hand  and  fingers;  the  patient  will  volunteer  the 
information  that  all  points  hurt;  but  if  the  tendon 
sheath  is  involved,  pressure  upon  it  throughout  its 
course  causes  an  immediate  and  involuntary  expression 
of  pain,  and  while  before  the  patient  has  allowed  his 
hand  to  remain  passive  in  yours,  he  will  now  attempt 
to  withdraw  it  voluntarily,  and  there  is  no  doubt  in 
your  mind  of  the  exquisite  tenderness  over  this  area. 
If  this  tenderness  is  outlined  by  the  extent  of  the  sheath, 
your  diagnosis  is  nearly  made.  As  a  matter  of  fact,  the 
greatest  tenderness  is  generally  complained  of  on 
deep  pressure  at  the  proximal  end  of  the  finger  sheaths 
in  the  palm  of  the  hand,  just  over  the  metacarpo- 
phalangeal  articulation.  I  have  seen  a  lacerated  wound 
on  the  back  of  the  finger,  which  was  inflamed  and 
naturally  tender,  show  much  less  sensitiveness  than 
the  infected  sheath  on  the  opposite  side-  of  the  finger 
where  there  was  no  injury.  Now  make  passive  ex- 
tension of  the  finger,  and  the  patient  immediately 
complains  of  severe  pain  along  the  tendon  sheath, 
very  often  again  most  marked  at  the  site  of  the  meta- 
carpophalangeal  articulation.  This  is  a  valuable 
symptom.  The  flexion  of  the  fingers  is  of  less  impor- 
tance and  is  probably  due  to  several  factors — the 


ACUTE  TENOSYNOVITIS  211 

arthritis  in  the  finger-joints,  possibly  irritation  of  the 
adjacent  filaments  of  the  median  or  ulnar  nerve,  and 
again,  possibly  because  it  lessens  the  tension  upon  the 
tendon.  The  finger  is  generally  held  rigid  in  that 
position  and  a  difference  is  readily  seen  between  the 
simple  flexion  occurring  in  the  adjacent  swollen 
fingers  and  the  rigid  flexion  of  the  infected  finger.  So 
marked  is  this  that  often  one  is  able  to  diagnosticate 
an  extension  into  the  palmar  sheath,  for  instance, 
from  the  little  finger  sheath,  since  the  character  of  the 
flexion  changes  in  that  case  at  once  in  the  fingers 
supplied  by  these  tendons  which  pass  through  this 
common  sheath.  Mauclaire  has  described  a  claw-hand 
position,  but  I  have  not  found  it  to  be  characteristic  of 
acute  inflammation,  but  to  be  rather  the  evidence  of  an 
old  chronic  untreated  tenosynovitis. 

There  are  two  clinical  types  to  be  differentiated: 
First,  that  variety  in  which  the  infection  is  a  local  one, 
generally  of  staphylococcic  origin,  commonly  following 
lacerated  wounds.  Here  we  have  a  local  infection 
beginning  slowly;  plastic  adhesions  may  be  present, 
limiting  the  infection  to  a  particular  part.  There  is  a 
little  general  reaction,  but  the  local  evidences  of  inflam- 
mation are  marked.  A  second  type  is  that  in  which 
the  injury  is  generally  a  slight  one,  a  pin  prick  or  an 
insignificant  cut.  It  is  generally  of  streptococcic  origin. 
The  infection  is  carried  to  the  sheath  by  lymphatics. 
The  pain  is  severe,  and  within  a  few  hours  the  finger 
is  greatly  swollen,  red,  and  exquisitely  tender.  The 
evidences  of  toxemia  are  present  early,  but  the  red 
lines  running  up  the  arm,  indicative  of  a  lymphangitis, 
are  absent,  although  they  may  have  been  present  early. 
(See  Case  XVIII.)  This  type,  not  having  a  tendency 
to  plastic  adhesions,  spreads  rapidly  throughout  the 
entire  communicating  system  of  sheaths.  This  is  dis- 
tended with  a  fluid,  at  first  only  cloudy,  but  rapidly 


212     SYMPTOMS,  SIGNS,  DIAGNOSIS  OF  TENOSYNOVITIS 

becoming  purulent,  and  on  examination  we  find  thick 
pus  with  fragmented  nuclei,  due  probably  to  the 
virulent  toxins,  and  here  and  there  streptococci.  This 
type  is  prone  to  produce  early  rupture  and  extension 
into  the  connective-tissue  spaces. 

The  spontaneous  pain,  which  was  at  first  severe, 
grows  less  as  the  edema  develops,  and  may  delude  the 
surgeon  into  believing  that  the  process  is  subsiding. 
The  arm  seems  to  "fall  asleep,"  as  the  patient  ex- 
presses it.  Paresthesia,  with  creeping  and  itching 
sensations,  may  be  present,  and  especially  after 
rupture  of  the  sheath  the  tenderness  may  subside  to 
a  considerable  degree,  leading  the  surgeon  to  an  early 
erroneous  conclusion. 

SYMPTOMS,  SIGNS,  AND  DIAGNOSIS  OF  EXTENSIONS  FROM  INFECTIONS 
BEGINNING  IN  THE  LITTLE  FINGER. 

An  infection  of  the  sheath  of  the  tendon  in  the  little 
finger  may  be  localized  to  the  finger.  Extensions  to 
other  areas  are  probable,  however  (Fig.  77).  The  fol- 
lowing are  the  most  common:  (i)  The  ulnar  bursa; 
(2)  the  radial  bursa;  (3)  the  forearm;  (4)  fascial  spaces 
in  the  hand,  (a)  middle  palmar  space,  (b)  lumbrical 
space;  (5)  osseous  involvement,  middle  phalanx;  (6) 
joints,  proximal  interphalangeal,  wrist;  (7)  rupture  to 
the  surface. 

EXTENSION  TO  THE  ULNAR  BURSA. — In  the  fulmina- 
ting type,  where  the  opening  between  the  ulnar  bursa 
and  the  sheath  in  the  little  finger  is  present,  the  infec- 
tion extends  rapidly  throughout  the  hand.  It  should 
be  noted  here  that  the  frequency  of  extension  from  the 
one  to  the  other  is  greater  than  the  anatomical  opening 
would  explain ;  we  are  therefore  led  to  conclude  that  the 
opening  is  present  much  more  frequently  than  is  stated, 
or  there  is  some  other  method  of  extension,  possibly 
by  the  lymphatics. 


INFECTIONS  BEGINNING  IN  THE  LITTLE  FINGER    213 


This  extension  is  often  difficult  to  diagnosticate. 
It  is  marked  by  the  development  of  edema  in  the  hand, 
especially  upon  the  dorsum.  A  general  fulness  in  the 

FIG.  77 


To  epiphyseal  line  and  joint. 


To  connective-tissue  space  in  web 
and  around  lumbrical  muscle. 


To  surface  through  palmar  fascia. 
To  middle  palmar  space. 


Exceptionally  to  wrist  joint. 


Under  flexor  profundus. 


Schematic  drawing  showing  the  various  probable  extensions  from  an  infection 
of  the  tendon  sheath  of  the  little  finger. 

palm  is  found,  but  the  palmar  concavity  is  still  present. 
On  the  flexor  surface  the  greatest  swelling  is  just 
proximal  to  the  annular  ligament.  This  is  not  neces- 
sarily due  to  the  rupture  of  the  sheath  here,  but  to  the 


214     SYMPTOMS,  SIGNS,  DIAGNOSIS  OF  TENOSYNOVITIS 

looseness  of  the  tissues  which  permits  of  distention. 
This  swelling  is  accentuated  by  contrast  with  the  non- 
distensible  annular  ligament  distal  to  it.  The  swelling 
in  the  palm  occurs  at  the  same  time,  but  is  not  so  con- 
spicuous, owing  to  the  palmar  fascia.  This  also  diffuses 
the  swelling  so  that  it  is  not  accurately  limited  by  the 
outline  of  the  ulnar  bursa.  Moreover,  the  surrounding 
edema  tends  to  confuse  the  picture.  In  relation  to 
this  Forssell  states: 

"One  very  seldom  finds  in  acute  infections  of  the 
bursae  so  great  a  collection  of  pus  within  the  latter 
as  to  cause  a  purely  mechancial  swelling  of  such  extent 
that  one  can  easily  see  it  from  the  outside.  The  wall 
of  the  bursa,  before  an  extensive  formation  of  exudate, 
is  necrotic  and  has  usually  permitted  the  accumulation 
to  escape  into  the  surrounding  connective-tissue 
spaces." 

As  to  fluctuation,  Mauclaire  says:  "Fluctuation  is 
almost  the  rule.  One  can  easily  notice  it  by  placing 
the  fingers  above  and  below  the  annular  ligament." 
While  I  agree  that  a  sense  of  fluctuation  can  be  noted 
by  this  maneuver,  yet  the  edema  and  swelling  are  of 
such  a  character  that  I  cannot  attach  the  significance 
to  it  that  is  given  by  Mauclaire.  One  should  never 
wait  for  this  symptom  before  operating.  In  chronic 
tenosynovitis,  such  as  tuberculous  infection,  the  symp- 
tom is  of  undoubted  value. 

The  most  conspicuous  and  valuable  sign  is  the  ex- 
tension of  the  exquisite  tenderness  to  the  area  involved. 
It  should  be  remembered  that  this  is  absent  after  a 
few  days.  The  wrist  becomes  fixed,  the  thumb  shows 
tenderness  to  pressure,  and  particularly  on  passive 
movement  is  the  sensitiveness  noted.  It  is  seen  readily 
of  how  much  importance  this  latter  symptom  is  in 
diagnosticating  an  extension  to  the  ulnar  bursa  from  the 
little  finger.  We  note  that  while  at  first  the  symptoms 


INFECTIONS  BEGINNING  IN  THE  LITTLE  FINGER    215 

are  limited  to  the  little  finger  and  slight  changes  in  the 
ring  finger  because  of  its  juxtaposition,  all  at  once  the 
thumb  begins  to  show  the  characteristic  signs  of  con- 
tracture  and  tenderness,  while  the  index  and  middle 
fingers  remain  unchanged  except  for  the  increase  of 
pain  on  passive  extension  explained  above.  This  sen- 
sitiveness of  the  thumb  may  be  due  to  either  the 
juxtaposition  of  the  sacs  or  to  a  real  extension  into 
its  sheath. 

At  first  there  may  be  a  diffuse  redness  of  the  palm 
and  dorsum,  but  it  rapidly  gives  place  to  a  whitish  or 
even  cyanotic  hue.  Above  the  wrist,  however,  the 
tissue  generally  takes  on  a  marked  red  color,  which 
later  becomes  violaceous.  The  temperature  and  pulse 
may  not  be  of  any  diagnostic  importance.  Ordinarily, 
after  the  infection  has  lasted  a  few  days  and  the 
walling-off  process  has  begun,  the  temperature  is 
that  of  the  local  accumulation  of  pus  and  varies 
with  the  freedom  of  drainage.  In  the  first  few  days, 
however,  the  systemic  absorption  bears  no  relation 
to  the  abscess  formation  and  cannot  be  relied  upon 
for  diagnostic  purposes. 

EXTENSION  TO  THE  RADIAL  BURSA. — This  is  diag- 
nosticated as  following  an  ulnar  bursitis  by  the  in- 
creased swelling  and  tenderness  in  the  thenar  eminence 
and  along  the  sheath  with  the  associated  symptoms 
described  above.  The  tumefaction  of  the  thenar  area 
is  not  that  of  abscess  in  the  thenar  space.  Forssell 
states  that  this  extension  occurred  in  6  out  of  29  cases 
coming  under  his  observation — average  age,  fifty  to 
fifty-eight  years;  23  cases  remained  confined  to  the 
ulnar  bursa — average  age,  thirty-six  to  thirty-nine 
years.  In  my  own  experience  the  percentage  of  ex- 
tension is  greater. 

EXTENSION  TO  THE  FOREARM. — By  this  we  mean  a 
rupture  from  the  proximal  end  of  the  sheath  and  an 


216    SYMPTOMS,  SIGNS,  DIAGNOSIS  OF  TENOSYNOVITIS 

extension  along  the  connective-tissue  spaces,  or  rather 
the  intermuscular  spaces.  As  I  have  already  pointed 
out,  the  pus  passes  between  the  pronator  quadratus  and 
the  flexor  profundus  to  the  area  between  the  latter 
and  the  interosseous  membrane,  and  at  about  the 
middle  of  the  area  it  passes  more  superficially  and  to 
the  ulnar  side  along  the  ulnar  artery  and  nerve.  I 
have  had  opportunity  to  verify  this  area  of  extension 
many  times  in  cases  I  have  operated  upon,  and  have 
also  seen  it  in  one  fatal  case  I  had  an  opportunity  to 
dissect  (Case  XXII).  This  extension  is  characterized 
by  a  brawny  induration  that  should  not  be  confused 
with  the  softness  of  an  edema.  No  fluctuation  should 
be  expected,  since  the  accumulation  lies  too  deeply. 
This  extension  is  marked  also  by  the  loss  of  the  rela- 
tive swelling  immediately  above  the  annular  ligament 
due  to  the  distended  upper  end  of  the  sheath.  This 
swelling  is  not  any  less,  but  that  of  the  arm  is  greater. 
The  tenderness  may  become  less,  so  it  cannot  be 
depended  upon  as  a  symptom.  The  redness  is  generally 
greater,  and  spontaneous  pain,  while  at  first  marked, 
rapidly  subsides  (see  Chapter  XXVI). 

At  this  time  some  pus  may  accumulate  subcu- 
taneously  above  the  wrist,  due  to  lymphangitis,  and 
lead  to  the  supposition  that  there  is  no  pus  under  the 
tendons,  so  that  valuable  time  is  lost. 

EXTENSION  TO  THE  LUMBRICAL  AND  PALMAR  SPACES. 
— One  of  the  commonest  sites  of  extension  is  into  the 
lumbrical  and  palmar  spaces.  The  involvement  of 
the  adjacent  lumbrical  space  occurs  so  frequently  as 
to  keep  one  continually  on  his  guard,  since  from  this 
involvement  of  the  tendon  of  the  adjacent  finger  or 
palm  occurs  very  easily.  It  is  characterized  by  ten- 
derness, swelling,  and  pain  at  the  site.  The  tissue 
between  the  fingers  on  the  dorsum  of  the  corresponding 
web  is  generally  swollen  and  red ;  the  side  of  the  finger 


INFECTIONS  BEGINNING  IN  THE  LITTLE  FINGER     217 

adjacent  to  the  infected  finger  is  often  red  and  tender. 
It  begins  to  swell  slightly,  and  by  extension  the  tendon 
sheath  of  that  finger  often  becomes  involved  with  the 
characteristic  symptoms  and  signs.  In  involvement 
of  the  lumbrical  space  alone,  the  swelling  of  the  area 
involved  is  marked.  The  middle  palmar  space  is  most 
commonly  involved,  either  by  extension  along  the 
lumbrical  space  or  from  rupture  of  the  ulnar  bursa 
which  lies  in  juxtaposition.  The  thenar  space  is  never 

FIG.  78 


f  To  epiphyseal  line 
<  of  middle  phalanx 
(  and  joint. 


To  fascial  spaces  about 
web  and  around  the 
lumbrical  muscles. 
i  (  Through  palmar  fascia 

to  surface. 
To  thenar  space. 


Schematic  drawing  showing    probable    extensions  from  an  infection  of  the 
tendon  sheath  of  the  index  finger. 


primarily  involved  in  the  little  finger  infections.  In- 
volvement of  the  middle  palmar  space  is  characterized 
by  a  slight  bulging  of  the  palm  replacing  the  normal 
concavity.  The  symptoms  and  signs  of  this  complica- 
tion, as  well  as  those  observed  in  osseous  and  joint 
involvement,  will  be  discussed  in  the  subsequent  pages. 
(See  Chapters  XVII  and  XXVIII.)  Mention  should 
also  be  made  of  the  frequency  of  rupture  of  the  sheath 
through  the  palm  to  the  surface  at  the  proximal  end  of 
the  finger  sheath  in  neglected  cases. 


218    SYMPTOMS,  SIGNS,  DIAGNOSIS  OF  TENOSYNOVITIS 

SYMPTOMS,  SIGNS,  AND  DIAGNOSIS  OF  EXTENSIONS  FROM  INFECTIONS 
BEGINNING  IN  THE  INDEX,  MIDDLE,  AND  RING  FINGER. 

Involvement  of  the  index,  middle,  and  ring  fingers 
presents  the  same  signs  as  the  little  finger.    The  only 

FIG.  79 


To  epiphyseal  line 
of  middle  phalanx, 
and  to  joint. 


To  fascial  spaces  about 

web  and  around  the 

lumbrical  muscles. 
Through  palmar  fascia 

to  surface. 

To  middle  palmar  space; 
exceptionally,  the  thenar  space. 

Schematic  drawing  showing  probable  extensions  from  infection  of  the  tendon 
sheath  of  the  middle  finger. 


FIG.  80 


To  epiphyseal  line 
of  middle  phalanx, 
and  to  joint. 


To  fascial  spaces  about 
web  and  around  the 
lumbrical  muscles. 
,  f  Through  palmar  fascia 
\    to  surface. 

To  middle  palmar  space. 

Schematic  drawing  showing  probable  extensions  from  the  infection  of  the 
tendon  sheath  of  the  ring  finger. 

difference  is  that  here  the  paths  of  extension  are 
different.  The  most  common  extension  is  into  the 
lumbrical  space  on  either  side;  from  here  the  pus 


EXTENSIONS  FROM  INFECTIONS  IN  THE  FINGERS   219 

extends  into  either  the  palm  as  noted  below,  or  to  the 
dorsum  in  the  web  or  at  times  to  the  adjacent  tendon 
sheath.  (See  Case  VII.)  The  fingers  differ  somewhat 
in  the  method  of  their  extension  into  the  palm,  as 
will  be  seen  by  noting  the  accompanying  drawings 
(Figs.  78,  79,  and  80).  The  middle  and  ring  fingers 

FIG.  81 


Schematic  drawing  made  from  a  dissection  of  a  hand  in  which  the  injec- 
tion was  made  along  the  tendon  sheath  of  the  index  finger.  Mass  filled 
the  thenar  space  and  extended  along  the  lumbrical  muscle. 

drain  into  the  middle  palmar  space,  and  the  index 
finger  into  the  thenar  space. 

In  common  with  the  little  finger  these  also  present 
less  often  involvement  of  the  middle  phalanx,  the 
proximal  interphalangeal  joint,  and  rupture  to  the 
surface  most  infrequently  of  all. 

As  illustrating  the  extension  from  the  index  finger 
into  the  thenar  space,  with  no  involvement  of  the 


220    SYMPTOMS,  SIGNS,  DIAGNOSIS  OF  TENOSYNOVITIS 

middle  palmar  space,  I  record  the  case  of  Miss  M., 
seen  with  Dr.  Besley  at  the  Post-Graduate  Hospital. 
The  probability  of  this  extension  was  pointed  out  by 
myself  experimentally  some,  time  previous  to  the 
opportunity  to  observe  a  clinical  case  proving  the 
assumption.  Fig.  81  shows  such  a  condition. 

CASE  XL — Seen  in  consultation  with  Dr.  F.  A.  Besley 
at  the  Post-Graduate  Hospital,  October,  1906. 

History. — Patient  stated  that  twenty-four  hours  before 
she  had  run  a  needle  in  the  distal  phalanx  of  the  index 
finger  of  the  right  hand.  Inside  of  seven  or  eight  hours 
the  pain  became  severe  and  she  arrived  at  the  hospital 
complaining  of  excessive  pain  and  tenderness. 

Examination. — Patient's  temperature,  102.5°;  pulse,  100. 
Index  finger  seemed  to  be  slightly  swollen.  Tenderness 
was  present  over  the  entire  finger  and  the  lower  portion 
of  the  hand  on  the  radial  side  without  localization  at 
any  point.  The  glands  in  the  axilla  were  swollen,  those 
in  the  elbow  not  involved.  No  lymphatic  lines  seen. 

Treatment. — A  diagnosis  of  lymphatic  infection,  possibly 
tenosynovitis,  was  made  and  hot  boric  dressings  applied. 

The  next  morning  the  temperature  had  fallen  markedly 
and  the  patient  insisted  on  leaving  the  hospital.  She 
returned  in  two  days  with  all  the  evidences  of  acute 
systemic  infection — temperature,  102°;  headache  and 
sleeplessness.  Locally  the  finger  presented  about  the 
same  appearance  as  when  seen  two  days  before,  except 
that  there  was  a  slight  increase  in  swelling  and  the  thenar 
space  from  the  adduction  crease  in  the  thumb  seemed  to 
be  ballooned  out  from  the  remainder  of  the  hand.  The 
concavity  of  the  palm  was  still  present. 

Diagnosis  of  previous  tenosynovitis  in  the  index  tendon 
sheath,  with  rupture  at  its  proximal  end  and  involvement 
of  the  thenar  space  was  made. 

On  operation  pus  was  found  to  be  present;  there  was  a 
very  large  accumulation  in  the  thenar  space,  which  was 
drained  by  through-and-through  drainage  from  the  palm 
to  the  dorsum  between  the  metacarpal  bones  of  the  index 
finger  and  thumb.  The  tendon  sheath  of  the  index  finger 
was  opened  throughout  its  extent. 


EXTENSIONS  FROM  INFECTIONS  IN  THE  FINGERS   221 

Course. — Patient's  temperature  rapidly  subsided  and 
in  two  or  three  days  was  normal  or  99°.  Infection  of 
the  thenar  space  had  entirely  subsided  at  the  end  of  seven 
days,  and  the  wounds  healed  promptly.  The  opening  in 
the  tendon  sheath  of  the  index  finger,  however,  was 
present  for  four  weeks,  necessitating  repeated  dressings. 

Result. — Recovery  with  all  functions  except  flexion  of 
the  distal  phalanges  of  the  index  finger. 

FIG.  82 


To  joint. 


To  surface. 
To  thenar  space.  .. 


Under  flexor  profundus. 


Schematic  drawing  showing  probable  extensions  from  infection  of  the  tendon 
sheath  of  the  thumb.     (Flexor  longus  pollicis.) 


SYMPTOMS,  SIGNS,  AND  DIAGNOSIS  OF  EXTENSIONS  FROM  INFECTION 
BEGINNING  IN  THE  RADIAL  BURSA. 

The  gravity  of  tenosynovitis  of  the  flexor  longus 
pollicis  of  the  thumb  has  long  been  recognized.  The 
symptoms  and  signs  common  to  the  other  fingers  are 


222    SYMPTOMS,  SIGNS,  DIAGNOSIS  OF  TENOSYNOVITIS 

found  here.  To  diagnosticate  the  extension  into  the 
radial  bursa  and  then  to  the  ulnar  bursa  is  more 
difficult  (Fig.  82).  Let  us  suppose  the  thumb  has  been 
the  seat  of  the  primary  infection.  This  member  is 
very  painful,  the  index  finger  slightly  sensitive,  and  the 
other  three  fingers  hardly  at  all.  After  a  time,  if  the 
infection  spreads  throughout  the  sheath,  all  the  fingers 
become  more  painful  to  passive  extension,  and  should 
the  infection  pass  over  into  the  ulnar  sheath  all  the 
fingers  become  flexed  and  the  pain  severe  upon  exten- 
sion of  the  tendons,  most  marked,  however,  in  the 
little  finger.  In  other  words,  it  assumes  the  character 
of  an  ulnar  sheath  infection.  The  tenderness  over  the 
sheath  is  not  always  so  marked  in  secondary  involve- 
ment, however,  due  possibly  to  the  previously  de- 
veloped edema.  I  recall  one  case  where  the  only 
marked  tenderness  was  at  the  base  of  the  little  finger. 
Here,  however,  owing  to  this  tenderness,  which  was  not 
present  at  the  base  of  the  other  fingers,  a  diagnosis  of 
involvement  of  the  ulnar  bursa  was  correctly  made. 
Forssell's  statistics  show  that  23  out  of  27  cases  of 
radial  bursitis  extended  to  the  ulnar  bursa — average 
age,  forty- three  years;  the  4  that  remained  confined  to 
the  radial  bursa  averaged  thirty-seven  and  one-half 
years  of  age.  It  cannot  be  emphasized  too  strongly 
that  in  the  early  state  of  secondary  involvement  of 
the  ulnar  bursa  there  is  no  marked  swelling  upon  the 
palmar  surface  and  that  there  is  no  special  tumefaction 
over  the  ulnar  bursa. 

One  fact  may  confuse  the  surgeon  in  that  the  ten- 
derness over  the  radial  bursa  may  be  absent.  Not 
only  that,  but  upon  operation  no  macroscopic  pus  may 
be  found  in  the  middle  part  of  the  sheath.  By  careful 
extension  of  the  incision  and  pressure  upon  the  two 
ends  pus  may  be  brought  into  the  wound. 

The  extension  of  the  infection  into  radial  bursa  is 


F ASCI AL-SP ACE  ABSCESSES  223 

generally  accompanied  by  a  swelling  above  the  anterior 
annular  ligament,  just  as  in  ulnar  bursa  infection.  It 
may  rupture  from  here  into  the  tissues  of  the  forearm, 
and  then  the  pus  lies  under  the  flexor  profundus  tendons 
as  previously  described  in  discussing  rupture  of  the 
ulnar  bursa.  (See  p.  149  and  Chapter  XXVI  for  com- 
plete discussion  of  forearm  extensions.) 

The  diagnosis  of  involvement  of  the  wrist-joint  will 
be  discussed  in  Chapter  XXVI. 


THE   SYMPTOMS,   SIGNS,   AND   DIAGNOSIS   OF  FASCIAL- 
SPACE    ABSCESSES. 

The  well-defined  spaces  I  have  described  as  being 
present  in  the  hand  may  be  infected  primarily,  or  sec- 
ondarily to  a  tendon-sheath  infection.  In  either  case 
the  symptoms  and  signs  are  the  same  except  that  the 
diagnosis  of  the  location  of  the  pus  is  simplified  when 
we  have  had  a  certain  finger  sheath  involved,  as  has 
already  been  pointed  out.  Let  us  discuss  the  question, 
however,  as  if  we  were  dealing  with  one  or  more  of  the 
spaces  without  relation  to  tenosynovitis.  The  student 
will  have  no  difficulty  in  combining  or  differentiating 
the  two  pictures  if  they  are  present  in  an  individual 
case,  and  the  differentiation  must  be  made,  since  in 
draining  a  tendon  sheath  we  do  not  drain  a  fascial 
space,  nor  vice  versa.  Each  must  be  treated  separately, 
even  if  in  a  given  case  the  two  infections  are  combined. 

The  symptoms  and  signs  may  be  divided  into  local 
and  general.  The  general  evidences  of  this  variety  of 
infection  do  not  differ  at  all  from  those  seen  elsewhere. 
The  temperature  often  reaches  103°  to  104°,  and  the 
restless  tossing  of  the  patient,  the  sleepless  nights,  the 
wandering  eye,  the  sweaty  brow,  and  the  flushed 
cheek  all  demonstrate  the  absorption  of  the  toxins, 
bound  in  closed  spaces,  with  no  means  of  exit. 


224    SYMPTOMS,  SIGNS,  DIAGNOSIS  OF  TENOSYNOVITIS 

Locally,  one  elicits  particular  pain  limited  to  the 
area  involved.  This  localization  of  the  pain  is  not  so 
definite,  however,  as  that  noted  in  the  synovial  sheath 
infection,  particularly  in  those  patients  in  whom  the 
mental  equilibrium  is  disturbed  as  a  result  of  suffering 
and  septic  intoxication.  After  a  number  of  days  the 
tenderness  and  pain  grow  less  severe,  owing  to  the 
edema  with  pressure  on  the  nerves.  Unfortunately, 
the  brawny  induration  so  helpful  in  diagnosticating 
subcutaneous  accumulations  of  pus  cannot  be  definitely 
elicited  upon  the  palmar  surface,  owing  to  the  palmar 
fascia  and  its  general  rigidity.  Upon  the  dorsal  surface, 
however,  the  induration  and  localized  tenderness  will 
aid  us  materially  in  distinguishing  between  the  doughy, 
pitting  edema  which  is  always  present  and  an  accumu- 
lation of  pus,  long  before  fluctuation  gives  its  tardy 
evidence.  The  position  of  the  fingers  is  worth  noting. 
Incident  to  any  inflammatory  process  about  the  palm  of 
the  hand,  with  its  consequent  edema,  the  fingers  tend 
to  become  flexed;  here,  however,  the  flexion  of  the 
fingers  is  neither  so  marked  nor  so  rigid  as  in  synovial- 
sheath  infection. 

THE  MIDDLE  PALMAR  AND  THENAR  SPACES. 

If  the  middle  palmar  space  be  involved,  we  are  often 
aided  in  making  the  diagnosis  by  the  site  of  the  primary 
injury.  Since  in  the  chapter  upon  pathogenesis 
(Chapter  XI)  the  routes  of  extension  from  various 
fingers  and  parts  of  the  hand  were  pointed  out,  it  is 
not  necessary  to  go  into  detail  upon  this  subject  again, 
although  an  example  may  be  given.  For  instance, 
in  Case  VIII  the  palmar  surface  was  evidently  in- 
volved. The  fistulous  tract  on  the  dorsum  opened 
over  the  metacarpal  bone  of  the  hypothenar  area 
dorsally;  but  with  the  facts  in  mind  that  the  meta- 


THE  MIDDLE  PALMAR  AND  THENAR  SPACES     225 

carpal  bone  of  the  middle  finger  was  fractured  and 
infected,  and  also  that  pus  in  the  subaponeurotic  space 
would  tend  to  point  at  the  side,  a  diagnosis  of  pus  in 
the  middle  palmar  space  rather  than  the  hypothenar 
was  made.  Drainage  of  this  space  was  instituted,  and 
the  immediate  fall  of  the  temperature,  with  rapid 
convalescence,  substantiated  the  diagnosis.  Tender- 
ness most  marked  over  this  area,  swelling  of  the  whole 
hand,  marked  upon  the  ulnar  side  (or  it  is  better  to  say 
without  the  excessive  swelling  of  the  thenar  area  which 

FIG.  83 


Photograph  showing  the  ballooning  of  the  thenar  space  when  filled  with  pus. 
Note  that  the  concavity  of  the  palm  still  remains. 

characterizes  infection  of  that  space),  aid  us  in  making 
the  differential  diagnosis.  The  obliteration  of  the  con- 
cavity of  the  palm  and  the  presence  of  a  slight  bulging 
is  almost  pathognomonic,  since  while  edema  may  pro- 
duce an  obliteration  of  the  concavity,  I  have  never 
seen  it  produce  a  bulging  or  convexity — a  condition 
which  I  have  seen  in  all  large  abscesses  of  the  middle 
palmar  space.  Attention  is  drawn  to  the  relative 
swelling  of  the  thenar  and  palmar  areas,  since  in  palmar 
infections  the  swelling  of  the  two  might  be  almost  the 
same,  owing  to  the  rigidity  of  the  palmar  fascia  over 
15 


226    SYMPTOMS,  SIGNS,  DIAGNOSIS  OF  TENOSYNOVITIS 

the  one  and  its  absence  over  the  other,  the  swelling 
of  the  thenar  space  being  due  to  associated  edema. 
On  the  contrary,  however,  infection  of  the  thenar  area 
is  characterized  by  a  much  greater  swelling  in  the  thenar 
than  the  more  resistant  palmar  tissue;  and,  moreover, 
the  swelling  of  the  thenar  region  is  greater  than  that 
due  to  the  collateral  edema  of  midpalmar  infection 
(Fig.  83).  ^ 

The  position  of  the  fingers  does  not  aid  much,  though 
we  expect  the  middle,  ring,  and  little  fingers  to  be 
held  in  their  characteristic  positions  more  markedly 
than  the  index  when  the  middle  palmar  space  is  in- 
volved, while  the  converse  is  true  in  thenar-space 
involvement.  The  slight  rigidity  of  the  thumb,  in 
contradistinction  to  its  involvement  in  thenar  infection, 
also  aids  one  in  making  the  differential  diagnosis  be- 
tween the  two  spaces.  It  is  well  to  remember  that  the 
fingers  can  be  moved  from  their  positions  with  much  less 
pain  than  is  elicited  when  the  fingers  are  involved  in  a 
tenosynovitis. 

The  great  difficulty  in  making  the  diagnosis,  however, 
is  not  in  those  cases  in  which  the  question  is  only 
which  space  is  involved;  it  is  when  we  ask  ourselves, 
Are  they  both  involved?  or  when  we  wish  to  know 
whether  a  midpalmar-space  infection  has  spread  over 
into  the  thenar  space,  or  vice  versa.  Fortunately, 
however,  the  thenar-space  infection  does  have,  to  a 
certain  extent,  that  induration  which  has  been  spoken 
of  as  being  absent  in  infections  under  the  palmar 
fascia,  and  this  aids  us,  slightly  at  least,  to  differentiate 
between  collateral  edema  and  pus  in  this  space.  More- 
over, the  history  helps  us  some.  Given  a  primary 
palmar-space  infection  for  several  days,  we  note  a 
rapid  increase  of  the  size  of  the  thenar  area ;  the  edema 
upon  the  dorsum,  which  has  not  been  so  great  as  that 
upon  the  ulnar  side  of  the  hand,  becomes  greater;  the 


THE  MIDDLE  PALMAR  AND  THENAR  SPACES     227 

palmar  surface  swelling  becomes  very  marked,  the 
tissues  of  the  thenar  area  seeming  to  balloon  out,  as 
it  were,  from  the  adduction  crease  of  the  thumb;  the 
thumb  metacarpal  is  pushed  away  as  far  as  possible 
from  the  hand,  and  the  flexion  of  the  distal  phalanx 
becomes  more  marked,  although  lacking  the  rigidity 
of  synovial  infection  of  the  flexor  longus  pollicis. 
In  such  a  case  we  now  fear  an  extension  into  that 
space. 

The  extension  of  an  infection  from  the  thenar  to 
the  palmar  space  is  not  so  common,  fortunately,  since 
diagnosis  is  made  earlier  and  the  proper  treatment 
instituted. 

The  immense  size  to  which  these  infected  hands  may 
grow  can  hardly  be  believed  unless  they  are  seen.  I 
recall  particularly  a  patient  who  presented  himself 
with  such  a  hand  which  had  been  treated  for  four 
weeks  without  the  surgeon  having  diagnosticated  and 
opened  a  typical  middle  palmar  abscess.  It  is  that  of 
the  patient  whose  photograph  is  present  in  Case  XII. 
In  the  photograph  the  two  hands  are  upon  the  same 
level,  and  the  size  of  the  infected  hand  is  not  exagger- 
ated in  the  picture.  It  could  be  compared  to  nothing 
except  the  appearance  of  a  large  turtle.  The  patient 
had  had  ten  to  fifteen  incisions  upon  the  fingers  and 
dorsum  of  the  hand  when  I  saw  him.  Only  one  incision, 
that  of  the  middle  palmar  space,  was  necessary  for 
drainage.  A  cupful  of  pus  was  evacuated,  and  the 
patient  ultimately  recovered  complete  function  of  his 
hand,  as  will  be  seen  by  examining  the  photographs. 
He  had  been  advised  by  several  surgeons  to  have  his 
hand  amputated.  There  might  be  some  excuse  for 
the  failure  to  diagnosticate  the  position  of  pus,  since 
the  long-continued  infection  had  so  obtunded  the 
nerves  that  he  complained  of  no  pain  or  tenderness. 
This  is  only  one  of  the  several  cases  that  have  been 


228    SYMPTOMS,  SIGNS,  DIAGNOSIS  OF  TENOSYNOVITIS 

seen  some  weeks  after  the  beginning  of  the  infection  in 
which  the  diagnosis  as  to  the  position  of  pus  had  not 
been  made,  and  in  consequence  of  the  apparently 
desperate  condition  of  the  hand  the  advice  to  amputate 
had  been  given,  and  yet  upon  proper  drainage  the 
patient  secured  serviceable  hands.  (See  Case  XVI.) 

FIG.  84 


Photograph  of  dorsum  of  infected  hand.      (See  Case  XII.)     Note  multiple 
ill-advised  incisions  upon  the  dorsum. 

CASE  XII. — Geo.  S.,  Streator,  Illinois.  History  in 
Brief. — Four  weeks  ago  patient  cut  his  hand  on  a  piece 
of  steel.  He  was  in  the  hospital  four  days,  and  it  appar- 
ently recovered.  Following  this,  numerous  small  pockets 
of  pus  developed  upon  the  fingers,  which  were  opened 
by  a  surgeon.  The  hand  began  to  swell  enormously, 


THE  MIDDLE  PALMAR  AND  THENAR  SPACES    229 


and  incisions  were  made  upon  the  dorsum  of  the  hand 
without  evacuating  much  pus.  The  patient  began  to 
suffer  from  systemic  intoxication. 

FIG.  85 


Photograph  of  palmar  surface  of  the  same  patient.  Note  wound  leading 
along  lumbrical  muscle  through  which  the  middle  palmar  space  was  drained. 
This  is  the  largest  hand  I  have  ever  seen.  The  pictures  show  the  right 
and  left  hands  respectively  of  the  same  patient.  They  are  on  the  same  level 
and  the  same  distance  from  the  camera.  (Case  XII.) 

Examination  on  Entrance. — General  condition:  tem- 
perature, 101°;  pulse,  120;  respirations,  26.  Marked 
headache  and  emaciation;  general  evidence  of  systemic 
intoxication.  Locally,  right  hand  swollen  to  two  and 
one-half  times  normal  size.  The  fingers  are  from  one  to 
one  and  one-half  inches  in  diameter.  The  hand  is  at  least 


230    SYMPTOMS,  SIGNS,  DIAGNOSIS  OF  TENOSYNOVITIS 

three  inches  thick,  swollen  both  upon  the  flexor  and 
extensor  surfaces.  Forearm  slightly  swollen.  Numerous 
incisions  upon  fingers  and  dorsum,  from  which  exude  a 
moderate  amount  of  pus.  There  is  little  or  no  tenderness 
about  the  hand. 

Upon  the  bulging  of  the  palm  and  the  lack  of  evidences 
of  tendon-sheath  involvement,  a  diagnosis  of  an  abscess 
in  the  middle  palmar  space  was  made.  Incision  along 
ring  finger  lumbrical.  A  cupful  of  pus  was  evacuated. 


FIG.  86 


Result  (Case  XII,  Figs.  84  and  85)  six  months  after  treatment. 
Note  perfect  function  of  all  fingers  and  all  joints. 

After-history. — Following  the  operation  the  tempera- 
ture rose  to  103°,  and  fell  the  next  day  to  99.8°.  It 
rose  to  102°  the  second  day,  and  then  fell  to  99.4°, 
from  which  time  it  gradually  reached  normal.  The 
swelling  slowly  subsided  under  hot  baths  and  active 
and  passive  movements,  so  that  the  patient  left  the 
hospital  at  the  end  of  five  weeks,  with  three-fourths 
function  in  the  hand,  and  at  the  end  of  four  months, 


DORSAL  ABSCESSES  231 

when  I  had  an  opportunity  to  examine  'the  patient,  the 
function  was  perfect  in  every  respect,  as  will  be  seen 
by  examining  the  photographs  (Figs.  84,  85,  and  86.) 


THE  HYPOTHENAR  SPACE. 

Involvement  of  the  hypothenar  space  can  often  be 
prognosticated  from  the  site  of  the  primary  injury, 
while  the  relative  lack  of  swelling  in  the  palm  and 
fingers,  with  absence  of  involvement  of  the  tendons, 
combined  with  the  ordinary  symptoms  of  abscess,  lead 
us  to  an  easy  diagnosis.  Fortunately,  the  hypothenar 
area  is  so  separated  from  the  remainder  of  the  hand 
that  it  is  seldom  involved,  secondarily,  to  palmar 
infection. 

DORSAL  ABSCESSES. 

An  infection  localized  under  the  subaponeurotic 
fascia  to  the  exclusion  of  the  subcutaneous  tissue  may 
be  difficult  of  differential  diagnosis.  However,  we  are 
aided  materially  if  we  remember  the  character  of  the 
primary  injury,  the  methods  of  extension  to  this  space 
already  mentioned,  and  the  local  evidences  of  infection 
upon  the  dorsum,  with  the  pitting  edema  of  the  sub- 
cutaneous tissue,  yet  lacking  the  brawny  induration 
and  localized  tenderness  of  a  subcutaneous  abscess. 

Reference  has  already  been  made  to  the  edema  upon 
the  dorsum,  due  to  the  fact  that  there  we  find  a  large 
area  of  loose  subcutaneous  tissue  in  which  serum  can 
accumulate,  and  secondly,  to  the  anatomical  distri- 
bution of  the  superficial  lymphatics,  which,  as  we 
have  pointed  out,  all  seek  the  shortest  course  from  the 
palmar  surface  to  the  dorsum.  Consequently,  one  often 
finds  much  greater  swelling  upon  the  latter  than  the 
former,  even  though  the  abscess  be  upon  the  palm. 
If,  however,  we  bear  in  mind  the  soft  pitting  of  edema, 
with  its  generalized  moderate  tenderness,  as  opposed 


232    SYMPTOMS,  SIGNS,  DIAGNOSIS  OF  TENOSYNOVITIS 

to  the  induration  with  slight  pitting  and  localized 
tenderness  of  the  abscess  in  this  tissue,  the  diagnosis 
is  easy.  One  should  never  wait  for  fluctuation  to 
make  a  diagnosis  of  abscess  formation;  it  should  be 
made  from  the  induration. 

FOREARM  ABSCESSES. 

It  is  well  at  this  time  to  speak  briefly  of  those  cases 
which  extend  into  the  forearm.  We  remember  that 
this  is  much  more  likely  to  occur  in  the  palmar  space 
infections  than  in  the  thenar  infections  (see  experi- 
ments), although  cases  are  reported  in  which  it  has 
extended  from  either  (Chevalet).  Personally,  I  have 
not  seen  a  single  case  in  which  an  extension  occurred 
from  an  uncomplicated  midpalmar  or  thenar-space 
abscess.  It  most  commonly  arises  from  a  radial  or 
ulnar  bursitis.  Here  we  would  note  the  sudden  in- 
crease of  evidences  of  inflammation  in  the  forearm; 
the  temperature  would  rise,  the  tenderness  over  the 
forearm  in  front  grow  greater,  and  the  swelling  become 
more  marked;  but  owing  to  the  fact  that  the  pus  is 
deep  under  the  muscles,  induration  would  be  absent 
until  later,  when  the  whole  area  became  involved,  and 
it  would  tend  to  come  to  the  surface  probably  a  few 
inches  above  the  wrist,  along  the  vessels.  (See  Chapters 
X  and  XXVI  for  a  full  discussion  of  this  subject.) 

Exception  must  be  made  of  those  cases  already 
noted  where  the  infection  develops  about  the  radial 
and  ulnar  arteries,  probably  of  lymphatic  origin.  Here 
the  abscess  is  not  so  deep,  yet  is  considerably  below 
the  skin  in  the  area  of  those  vessels. 

Osteomyelitis,  arthritis,  and  other  complications  and 
sequelae  have  no  peculiar  relation  to  fascial-space 
infection,  and  hence  will  not  be  considered  in  the 
symptoms,  diagnosis,  and  treatment.  They  will  be 
reserved  for  a  subsequent  chapter. 


DIFFERENTIAL  DIAGNOSIS  233 

DIFFERENTIAL  DIAGNOSIS. 

One  may  mistake  a  lymphatic  infection  for  a  teno- 
synovitis.  Here,  however,  the  red  lines  of  lymphatic 
involvement  running  up  the  arm  without  the  localized 
tenderness  over  the  tendon  sheaths,  the  slight  pain 
on  moving  the  fingers,  the  generalized  edema  of  hand 
and  arm  in  contradistinction  to  the  localized  swelling 
found  in  the  early  stage  of  tenosynovitis  aid  us  in  the 
diagnosis.  Again,  we  may  be  in  doubt  as  to  whether 
we  are  dealing  with  a  tenosynovitis  of  the  ulnar  or 
radial  bursa,  or  a  rheumatism  of  the  wrist.  I  have  seen 
several  such  cases.  In  one  case  it  was  difficult  to 
determine  whether  the  patient  was  suffering  from  a 
gonorrheal  rheumatism  of  the  proximal  interpha- 
langeal  joint  of  a  finger  or  a  gonorrheal  tenosynovitis 
with  secondary  involvement  of  that  joint.  The  latter 
assumption  was  later  found  to  be  the  condition  present. 
In  those  cases  where  there  is  a  lack  of  traumatic  his- 
tory and  an  apparently  spontaneous  development  of 
an  inflammation,  especially  at  the  wrist,  the  diagnosis 
may  be  most  difficult  in  spite  of  the  ease  with  which  a 
theoretical  differential  diagnosis  is  made.  Here,  again, 
however,  the  localized  tenderness  over  the  sheath  and 
pain  on  extension  of  the  finger  are  of  the  greatest 
importance;  moreover,  these  cases  are  always  virulent 
and  extend  rapidly,  so  that  if  it  be  a  tenosynovitis  the 
hand  grows  rapidly  worse.  In  a  rheumatism  there  is 
as  much  pain  on  the  dorsal  as  on  the  volar  surface; 
the  swelling  involves  the  wrist  more  than  the  hand, 
fingers,  or  forearm;  and  other  joints  may  be  involved. 
The  presence  of  a  gonorrhea  does  not  aid  us  materially, 
since  either  condition  may  follow.  Subcutaneous  in- 
fections are  seldom  difficult  to  differentiate.  One  case 
of  gonorrheal  tenosynovitis  of  the  tendon  sheaths  of  the 
dorsum  of  the  wrist  came  under  my  notice  in  which 


234    SYMPTOMS,  SIGNS,  DIAGNOSIS  OF  TENOSYNOVITIS 

the  diagnosis  of  rheumatism  had  been  made.  Here  the 
absence  of  any  tenderness  or  swelling  on  the  flexor  sur- 
face combined  with  swelling  and  tenderness  localized 
to  the  sheaths  confirmed  the  diagnosis. 

Forssell,  in  a  personal  communication,  has  drawn  my 
attention  to  three  cases  which  came  under  his  observa- 
tion in  which  there  was  a  palmar  infection  represented 
by  necrosis  of  a  part  of  the  palmar  fascia.  This  con- 
dition, he  states,  was  extremely  difficult  to  diagnosti- 
cate from  an  ulnar  bursitis.  Personally,  I  have  not 
met  with  such  a  case  and  can  offer  no  suggestion  as 
to  its  pathogenesis. 


CHAPTER    XV. 

THE  TREATMENT  OF  ACUTE  SUPPURATIVE 
TENOSYNOVITIS. 

GENERAL  CONSIDERATIONS  AND  REVIEW  OF  THE 
LITERATURE. 

BEFORE  discussing  my  own  views  as  to  the  site  and 
course  of  the  incisions  for  the  various  fingers  when  the 
diagnosis  of  tenosynovitis  has  been  made,  let  us  study 
the  suggestions  of  those  who  have  previously  made 
contributions  to  this  subject. 

Professor  Bier  (Berlin),  with  his  assistants,  has  been 
an  active  advocate  of  the  production  of  passive  hyper- 
emia  in  these  cases  of  infection  of  the  hand.  His 
method  consists  in  applying  a  constrictor  to  the  arm 
so  as  to  produce  a  moderate  passive  hyperemia  with- 
out causing  pain  and  without  restricting  the  arterial 
flow  of  blood.  The  constrictor  should  be  a  broad  band, 
and  to  prevent  pain  should  extend  from  two  to  four 
inches  up  and  down  the  arm.  It  should  be  so  applied 
that  the  full  amount  of  edema  does  not  appear  at 
once,  but  accumulates  gradually  for  from  three  to 
four  hours.  The  constrictor  is  left  on  from  sixteen 
to  twenty-four  hours.  After  an  interval  of  from  two  to 
four  hours  it  is  reapplied.  Small  incisions  are  made 
into  the  tendon  sheaths  or  other  sites  of  pus. 

Klapp  has  added  to  this  by  suggesting  the  use  of 
suction  cups,  these  being  applied  so  as  to  produce 
moderate  hyperemia  without  pain.  Cups  from  which 
the  air  can  be  exhausted  are  used  over  localized  accumu- 
lations of  pus.  Long  glasses  with  rubbers  at  the  end, 


236     TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 

which  can  be  applied  over  the  finger,  as  shown  by  the 
illustrations,  have  also  been  devised. 

In  involvement  of  the  connective-tissue  spaces,  it 
is  my  personal  opinion  that  these  appliances  may  be 
of  slight  value.  In  other  conditions  the  benefit  to  be 
derived,  it  would  seem,  is  so  slight  as  hardly  to  justify 
their  use.  Many  German  surgeons  have  maintained 
that  Bier's  methods  are  of  value  in  tendon-sheath 
infections,  but  personally  I  have  never  been  able  to 
secure  good  results  with  them,  except  possibly  in  a 
few  cases  where  there  has  been  a  sinus,  leading  down 
to  a  tendon  sheath.  The  sinus  seemed  to  close  more 
rapidly  under  the  suction  cup  of  Klapp  than  by  other 
means. 

In  order  to  prevent  rapid  absorption  of  toxins,  it 
is  my  habit,  after  operation  upon  exceptionally  virulent 
cases,  to  leave  on  an  Esmarch  constrictor  for  from 
twelve  to  twenty-four  hours  after  operation,  except 
that  a  constrictor  is  loosened  to  produce  only  a  slight 
hyperemia. 

I  cannot  but  feel  that  while  slight  benefit  may  occur 
in  some  cases,  the  so-called  Bier  treatment  of  infections 
of  the  hand  cannot  be  looked  upon  as  a  marked  aid. 

EXCERPTS  FROM  THE  LITERATURE. 

Klapp  and  other  surgeons  have  discussed  the  Bier 
method  of  treatment  in  these  cases  at  the  German 
Surgical  Congress.1 

Klapp  has  begun  to  make  free  incisions  in  the  tendon 
sheaths  at  the  lateral  surface  of  the  fingers  and  cut  the 
ulnar  bursa  throughout  its  length  with  the  exception 
of  the  anterior  annular  ligament,  using  alcohol  dress- 
ings, and  active  movements  the  first  day.  His  results 
have  apparently  been  as  satisfactory  as  those  obtained 

1  Berliner  klinische  Wochenschrift,  April  13,  1908,  No.  25. 


EXCERPTS  FROM  THE  LITERATURE  237 

by  Bier  and  Klapp  previously  where  they  made  small 
incisions  into  the  tendon  sheaths  and  applied  the  Bier 
constrictor.  By  this  method  he  had  treated  19  cases. 

1.  Ten    cases    of    pure    tendon-sheath    infection;    9 
healed  with  necrosis. 

2.  Two   cases'  of   subcutaneous   abscess   under   the 
tendon   with    necrosis   of   the   skin:  I    healed    and    I 
recovered  completely. 

3.  Six  cases  of  tendon-sheath  infection  complicated 
with  infected  phalangeal  fractures:  2  of  these  healed, 
and  4  became  necrotic. 

4.  One  case  developed  sepsis  and  died  on  the  twelfth 
day. 

Klapp  therefore  concludes  that  he  has  thus  answered 
the  question  as  to  whether  Bier's  good  results  came 
from  hyperemia  or  from  the  physiological  treatment. 
He  maintains  that  he  has  proved  that  it  came  from 
the  latter.  He  now  proposes  to  study  whether  good 
opening,  physiological  treatment,  and  Bier's  hyperemia 
will  not  produce  still  better  results. 

Klapp's  paper  was  discussed  by  Joseph,  who  sug- 
gested that  there  are  two  types  of  the  infection  which 
must  be  differentiated:  (i)  where  it  is  localized  to  the 
sheath,  not  showing  a  tendency  to  spread;  (2)  a  type 
which  shows  a  tendency  to  spread  beyond,  due  to 
the  great  virulence  of  the  infection. 

He  maintained  that  we  should  use  care  not  to  go 
beyond  the  zone  of  protection  which  Nature  has  thrown 
out. to  wall  off  the  infection,  whether  it  be  within  the 
sheath  or  without.  In  these  cases  we  should  use  the 
smallest  possible  incisions  and  Bier's  hyperemia. 

Kausch  stated  that  he  had  treated  a  large  number 
of  tendon-sheath  infections  after  Bier's  method,  and 
must  say  he  was  generally  well  satisfied  with  the 
result.  He  has  not  been  so  well  satisfied  with  the  very 
severe  cases.  In  the  beginning  he  used  small  incisions, 


238     TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 

then  medium-sized,  and  drained  with  passive  hyper- 
emia,  but  in  his  severe  cases  he  has  now  gone  back 
to  large  incisions,  although  not  as  large  as  formerly. 

Karewski  stated  that  he  could  not  attribute  his  bad 
results  to  the  Bier  method,  but  rather  to  the  fact  that 
his  material  was  ambulatory  and  could  not  be  correctly 
handled.  He  had  used  the  older  method  for  twenty- 
five  years.  He  now  makes  a  moderate-sized  incision, 
packs  lightly,  and  keeps  the  arm  at  rest  as  long  as 
there  is  fever.  Of  57  cases,  4  had  to  have  amputation 
of  the  fingers  at  once.  Of  the  53  cases  remaining,  9 
were  treated  by  lateral  incisions.  Of  the  53  cases,  42 
showed  good  results:  that  is,  79.25  per  cent.;  bad 
results,  5  cases,  or  9.5  per  cent.  This  result  is  better 
than  that  given  by  Dr.  Klapp. 

Forssell,  in  his  monograph  previously  referred  to, 
has  collected  the  opinions  of  various  surgeons,  and  I 
shall  quote  and  abstract  extensively  from  him.  He 
gives  the  results  of  his  own  experience  as  follows:1 

"Even  if  one  makes  smaller  incisions  into  the  sheath, 
at  least  according  to  the  experience  met  with  in  the 
Seraphimer-Lazarett,  one  rarely  succeeds  in  saving  the 
sheath  (Poulsen's  experience  was  the  opposite).  I 
have  often  attempted  to  treat  such  an  infection  with 
incision  at  each  end  of  the  tendon  sheath  and  with 
complete  exposure  of  the  surrounding  folds  of  the 
synovialis  (and  subsequent  washing  of  the  sheath 
with  water,  normal  salt  solution,  boric  acid  solution, 
iodoform-glycerin,  weak  carbolic  or  sublimate  solu- 
tions), but  only  on  three  occasions  was  this  treatment 
successful. 

"The  treatment  which  in  my  judgment  should  be 
used  in  most  cases  is  a  complete  splitting  of  the  sheath 
from  one  end  to  the  other.  Thus,  one  often  succeeds 
in  saving  at  least  the  inner  tendon  from  complete 
necrosis. 

1  Nordisches  Med.  Archiv,  1903,  Abt.  i,  Heft  3. 


EXCERPTS  FROM  THE  LITERATURE  239 

"For  the  opening  of  the  ulnar  sheath  on  the  forearm, 
if  for  some  reason  one  prefers  to  begin  the  incision 
here,  several  starting  points  are  at  his  command.  If 
one  can  determine  the  ulnar  pulse,  the  skin  incision 
is  made  one  centimeter  to  the  radial  side  thereof,  and 
after  cutting  through  the  fascia  meets  the  collected 
muscular  bundle  of  flexors  of  the  fingers,  at  whose 
ulnar  and  posterior  circumference  the  sheath  extends 
farthest  upward;  by  passive  movement  of  the  ulnar 
finger  it  is  now  a  simple  matter  to  know  the  lay  of  the 
land.  If  one  does  not  feel  the  ulnar  pulse,  nor  the  os 
pisiforme,  which  lies  close  to  the  ulnar  side  of  the 
ulnar  artery,  nor  the  unciform,  on  whose  radial  boun- 
dary the  incision  must  fall,  one  can  make  the  skin  in- 
cision on  the  border  of  the  middle  and  inner  third  of 
the  wrist-joint  and  then  dissect  layer  for  layer  down  to 
the  tendon  sheath. 

"If  it  is  a  case  of  inflammation  of  the  ulnar  sheath 
of  the  palm  and  the  tendon  sheath  of  the  little  finger 
it  is  often  preferable  to  begin  with  the  fissure  of  the 
latter.  Only  in  exceptional  cases  it  might  be  worth 
while  to  use  a  more  conservative  treatment,  and  that 
especially  in  such  cases  of  fresh  tenovaginitis,  where 
this  is  secondary  after  an  ulnar  bursitis;  in  such  cases 
one  can  occasionally  make  an  attempt  to  conquer  the 
inflammatory  process  by  washing  out  the  tendon 
sheath  through  incisions  made  in  either  end;  there  is 
little  danger  in  this  method,  and  if  successful,  it  insures 
complete  movability  of  the  little  finger. 

"The  skin  incision  must  then  be  laid  from  the  upper 
end  of  the  opened  little  finger  sheath,  up  toward  the 
hook  of  the  unciform  (i.  e.,  must  follow  the  radial 
boundary  of  the  hypothenar),  and  then  continued  in 
the  length  of  the  forearm  to  a  point  three  or  four 
centimeters  or  more  above  the  wrist.  After  cutting 
through  the  skin  and  the  subcutaneous  fat,  usually 


240     TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 

especially  developed  here,  the  palmar  aponeurosis,  the 
strong  anterior  annular  ligament,  and  the  forearm 
fascia  are  cleft,  the  superficial  vessels  cut  through  and 
ligated  (the  ligatures  being  left  long  because  the  vessels 
usually  draw  back  deep  into  the  tissue  and  with  their 
infected  ligatures  give  rise  to  collections  of  pus  which 
might  easily  be  overlooked),  after  which  the  sheath 
is  opened.  Even  when  the  infection  is  confined  to  the 
tendon  sheath,  the  incision  should  be  continued  in  the 
skin  and  soft  parts  until  it  gives  a  good  opening  into 
the  sheath,  through  which  this  can  be  easily  and  com- 
pletely packed  with  gauze. 

"In  continuing  the  incision,  it  must  not  be  allowed 
to  deviate  too  far  to  the  ulnar  side,  as  the  ulnar  nerve 
and  artery  might  thus  be  injured;  the  cut  can  and 
should  be  so  laid  that  neither  of  them  is  exposed.  The 
anterior  annular  ligament  is  best  cut  some  distance 
from  the  hook  of  the  unciform. 

"If,  however,  it  is  a  question  of  suppuration  of  the 
radial  bursa,  I  believe  that  a  complete  cutting  of  the 
anterior  wall  of  the  bursa  should  not  be  attempted- 
If  the  incision  is  made  in  the  early  stages  of  the  in- 
fection, one  may  have  the  satisfaction  of  seeing  the 
tendon  of  the  thumb  saved  and  the  infection  restricted ; 
the  tendon  cannot,  however,  be  saved  in  all  these 
cases,  and  sometimes,  moreover,  it  is  rendered  useless 
by  adhesions  to  neighboring  regions.  An  incision  of 
the  whole  length  of  the  sheath  is  to  be  regarded  as 
even  more  than  useless  when  it  is  attempted  in  more 
advanced  cases  where  there  is  no  chance  of  saving  the 
tendon  since  the  suppuration  is  kept  up  by  the  necrotic 
tendon;  moreover,  such  an  operation  lames  an  im- 
portant group  of  muscles  and  so  makes  the  thumb 
practically  useless. 

"How  then  should  one  proceed  in  suppurations  of 
this  order?  I  believe  there  are  three  ways  at  our 
command : 


EXCERPTS  FROM  THE  LITERATURE  241 

"i.  Incision  in  the  radial  bursa  above  and  below 
the  ligamentum  carpi,  sparing  the  nerve  of  the  thenar 
group.  The  first  mention  of  this  method  which  I 
have  found  in  the  literature  I  found  in  an  article  by 
Nicaise  (Gazette  medicate  de  Paris,  1870,  s.  615),  who, 
however,  opens  only  the  tendon  sheath  of  the  thumb 
under  the  carpal  ligament  and  not  the  radial  bursa; 
the  case  ended  in  necrosis  of  the  distal  part  of  the 
tendon  Surely,  then,  if  a  decided  improvement  has 
not  been  shown  within  the  first  twenty-four  hours, 
one  should  proceed  more  radically,  in  which  case  the 
choice  is  between  the  two  following  methods. 

"2.  Incision  as  in  I,  and  excision  of  the  long  flexor 
tendon  of  the  thumb.  Through  removal  of  the  tendon, 
which  is  usually  the  principal  reason  for  persistent 
suppuration,  one  also  gains  a  lessened  pressure  in  the 
radial  bursa  and  better  drainage  with  less  danger  of 
a  spreading  of  the  inflammation.  Primary  excision 
of  the  tendon  is  to  be  considered:  (i)  When  the  tendon 
is  already  necrotic  or  its  continuity  broken,  or  if  it 
is  so  injured  that  its  restitution  seems  hopeless;  (2) 
if  the  synovialis  is  infiltrated  with  pus  and  is  necrotic; 
(3)  in  case  of  inflammation  of  the  joint  or  fracture 
of  the  thumb,  whereby  the  functions  of  either  the 
interphalangeal  joint  or  of  the  tendon  are  completely 
interrupted;  (4)  in  people  of  age  or  poor  general  con- 
dition. 

"3.  A  more  or  less  complete  cutting  of  the  liga- 
mentum carpi  beginning  at  the  upper  edge  is  added 
to  the  above-mentioned  incision.  Complete  fissure  of 
the  ligamentum  carpi  can  be  carried  out  without  any 
direct  injury  to  the  motor  medianus  branch  to  the 
thenar  muscles;  nevertheless,  this  nerve  branch  in 
case  of  an  infection  of  the  edges  of  the  wound  might 
possibly  be  exposed  to  the  dangers  of  necrosis." 

I  am  in  receipt  of  a  letter  from  Dr.  Forssell,  under 

16 


242     TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 

date  of  September  10,  1908,  in  which  he  reiterates  his 
belief  in  free  incision.     It  is  abbreviated  as  follows: 

"With  regard  to  your  query,  whether  I  have  modi- 
fied my  opinion  of  the  complete  splitting  of  the  tendon 
sheath  from  the  end  of  the  finger  up  into  the  forearm, 
I  must  answer  that  I  still  adhere  to  it  with  the  excep- 
tion mentioned  on  pages  37  and  63  of  my  paper,  i.  e., 
I  still  make  attempts  sometimes  with  smaller  incisions 
and  irrigations  through  the  tendon  sheaths  of  the  thumb 
and  little  finger  when  a  tendon  sheath  has  there  given 
rise  to  an  infection  of  the  radial  or  ulnar  bursa  and  split 
the  tendon  sheath  of  the  finger  only  when  the  smaller 
incisions  do  not  lead  to  the  desired  results. 

"Prof.  Bier's  hyperemic  treatment  has  been  used 
by  me  for  a  few  cases  of  infection,  but  without  any 
appreciable  benefit,  this  being  also  my  experience  with 
cases  of  tendon-sheath  infection.  The  material  at  my 
disposal  may,  however,  have  been  too  slight  for  my 
forming  an  opinion  of  my  own  concerning  the  value 
of  the  Bier  method  for  tendon-sheath  infections.  At 
the  surgical  department  of  the  Karolinska  Institute 
(The  Royal  Seraphim  Hospital),  where  I  worked  out 
my  paper,  and  where  the  principles  I  advocated  gained 
general  approbation,  and  caused  a  considerable  im- 
provement in  the  results  obtained,  there  was  later  on 
a  good  deal  of  enthusiasm  felt  for  the  method  invented 
by  Bier;  but  I  was  told  that  some  time  ago  the  method 
was  discontinued,  since  it  had  given  several  very  un- 
favorable running  cases,  and  in  the  main  the  former 
old  method  of  treatment  has  been  taken  up  again. 

"Whatever  method  may  be  used,  I  feel  sure  that 
fatal  cases  will  have  to  be  deplored.  As  the  prophyl- 
axis, therefore,  is  invariably  of  the  very  greatest 
importance,  I  have  lately  come  to  the  conclusion  that 
one  way  of  trying  to  prevent  infections  of  the  fingers 
from  attacking  the  tendon  sheaths  is  by  previously 


EXCERPTS  FROM  THE  LITERATURE  243 

exposing  the  tendon  and  tamponing  it  around,  to  the 
extent  of  a  couple  of  centimeters.  This  proceeding 
should  be  of  special  use  in  necrosis  of  the  end  phalanx 
of  the  thumb  that  so  often  occurs  and  which  greatly 
endangers  the  tendon  sheath  of  the  thumb  and  thus 
also  the  bursa  of  the  hand. 

"The  method  has  been  proved  by  me  as  yet  in  but 
one  single  case,  though  with  success.  I  then  proceeded 
as  follows:  The  tendon  sheath  of  the  thumb  was  split 
to  the  extent  of  a  couple  of  centimeters,  the  tendon 
was  cut  near  its  attachment  on  the  end  phalanx,  and 
was  flexed  by  a  suture  in  the  vicinity  to  its  surround- 
ings, a  tampon  being  placed  around  it.  After  this  the 
necrotic  phalanx  with  the  tendon  attachments  was 
removed. 

"Seeing  the  interest  you  have  for  the  infections  of 
the  hand  in  general,  I  must  call  your  attention  to  the 
small  contribution  I  have  given  in  pages  32  and  33  of 
my  paper.  So  far  as  I  am  aware,  the  isolated  necrosis 
of  the  fascia  palmaris  has  not  previously  been  men- 
tioned in  literature,  which  is  singular,  since  both  from 
a  diagnostic  and  therapeutic  point  of  view  it  is  of 
great  interest.  I  have  recently  had  a  similar  case 
under  treatment.  An  English  sailor  a  fortnight  pre- 
vious to  being  admitted  to  the  hospital  had  punctured 
his  hand  with  a  nail.  Besides  the  mark  of  the  injury, 
there  was  great  soreness  in  the  palm,  accompanied  by 
considerable  swelling  of  both  palm  and  back  of  the 
hand,  with  a  very  observable  crooking  of  the  fingers, 
together  with  pain  when  moved,  but  no  tenderness 
when  the  fingers  themselves  were  subjected  to  palpa- 
tion. The  diagnosis  was  made  of  a  probable  abscess 
in  or  around  one  of  the  aforesaid  fascia,  which  was 
found  to  be  necrotic  in  the  great  part  of  its  extent, 
this  without  any  appreciable  accumulation  of  pus  in 
the  vicinity.  It  w^ould  be  interesting  to  hear  whether 


244     TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 

you  have  had  any  occasion  of  observing  a  case  of  this 
localizing  of  the  infection." 

W.  Heineke,  in  his  Anatomic  und  Pathologic  der 
Schleimbeutel  und  Sehnenscheiden,  Erlangen,  1868,  p. 
79,  speaks  of  the  acute  inflammations  of  the  tendon 
sheaths  of  the  hand: 

"The  only  cure  in  these  malignant  inflammations  is 
to  be  found  in  an  early  and  extensive  incision ;  thus,  one 
can  sometimes  prevent  a  necrosis  of  the  tendon,  but 
one  must  not  expect  too  much  in  this  direction.  After 
cutting  several  openings,  one  can,  by  use  of  the  drain, 
help  the  outflow  of  pus  and  the  cleaning  of  the  wound." 

An  article  by  Scheide1  shows  what  a  lack  of  even 
elemental  knowledge  there  has  been  in  the  past  in 
regard  to  the  position  of  the  pus  in  these  cases.  He 
warns  against  hot  cataplasm  treatment  of  these  diseases 
and  recommends  that  introduced  by  von  Volkmann,  the 
so-called  vertical  suspension  of  the  arm  together  with 
continuous  ice  applications,  and  even  painting  with 
iodine. 

"In  very  great  swellings,  and  excessive  overfilling 
of  the  veins,  numerous  stabs  with  a  very  sharp  knife 
often  do  good  service.  When  the  period  of  progressive 
inflammation  has  passed  and  with  it  the  danger  of 
death,  when  the  healing  has  begun,  then  the  question 
will  again  be,  What  operations  are  necessary?  Many 
a  necrotic  phalanx,  many  a  finger  whose  tendon  sheath 
has  become  purulent,  will  have  to  be  removed ;  and  now 
another  question  becomes  of  primary  importance,  the 
greatest  possible  functional  activity  of  the  remaining 
parts. 

"This  latter  is  most  frequently  hindered  through 
the  necessary  fixation  of  the  hand  for  weeks  and 
months,  thus  causing  the  fingers  to  lose  a  great  part 

1  Ueber  Hand  und  Fingerverletzungen,  Volkmann 's  Sammlung  klinischer 
Vortrage,  1871,  No.  29,  Note  i. 


EXCERPTS  FROM  THE  LITERATURE  245 

of  their  power  of  motion.  The  well-known  changes  to 
which  joints  are  subject  when  kept  stiff  for  a  long 
while  seem  to  take  place  especially  quickly  in  these 
small  joints  under  the  influence  of  rest  and  the  inflam- 
mation of  the  surrounding  tissue.  One  distinctly  feels 
then  how  in  bending  pseudoligaments  snap  or  the 
capsule  tears.  With  the  necessary  patience  and  endur- 
ance one  can  master  these  disturbances  without  a 
doubt.  But  a  great  deal  of  trouble  to  the  physician 
and  pain  to  the  patient  would  be  avoided  if  immedi- 
ately after  the  first  period  of  reaction  simple  passive 
exercises  were  given  whenever  the  dressing  was  changed 
and  so  prevent  any  severe  stiffening  of  the  joint." 

Schiller1  shows  the  same  lack  of  anatomical  knowl- 
edge. His  remarks  are  typical  in  that  they  show  a 
lack  of  tendency  to  make  an  early  diagnosis.  His 
drainage  under  the  anterior  annular  ligament  should 
also  be  condemned  The  same  may  be  said  concerning 
the  remarks  of  Tilleaux,  which  follow: 

"If  after  a  tendonal  panaritium  of  the  thumb  a 
doughy  swelling  along  the  arterioradialis  of  the  fore- 
arm is  noticeable,  pressure  there  and  on  either  side  of 
the  ligamentum  carpi  volare  is  very  painful,  while  the 
fingers  are  crooked,  it  is  advisable  to  make  a  few  in- 
cisions immediately,  if  possible,  along  the  line  of  the 
flexor  longus  pollicis,  into  the  tendon  sheath  as  far  as 
the  muscle,  in  order  to  prevent  further  changes, 
especially  the  occurrence  of  pyemia  or  septicemia.  The 
incisions  are  made  to  the  best  advantage  on  the  fore- 
arm outward  (radially)  from  the  arterioradialis  and 
along  it.  In  some  cases  this  is  sufficient,  as  evidently 
the  whole  of  the  great  tendon  sheath  is  not  always 
affected  from  the  very  beginning,  but  only  its  radial 
half.  In  other  cases,  further  incisions  in  the  great 

1  Chirurgisch-Anatomische  Studien   uber   die  Sehnenscheiden   der   Hand, 
Deutsche  med.  Wochenschrift,  1878. 


246     TREATMENT  OP  SVPPURATIVE  TENOSYNOVITIS 

tendon  sheath,  in  the  ulnar  side,  are  necessary.  Here 
an  incision  is  made  to  the  best  advantage  close  above 
the  anterior  annular  ligament  and  at  that,  not  exactly 
in  the  centre,  but  to  avoid  injuring  the  median,  more 
toward  the  ulnar  side  and  in  the  direction  of  the  long 
axis  of  the  forearm.  That  one  should  put  drains  in 
all  incisions  (best  under  the  ligamentum  carpi  volare), 
wash  out  the  pockets  with  an  antiseptic  fluid,  and  band- 
age the  wound  antiseptically,  I  will  only  mention  in 
passing.  Sometimes  even  these  incisions  are  not  suffi- 
cient; then  one  must  add  similar  ones  in  the  palm  and 
in  the  forearm." 

P.  Tilleaux1  speaks  of  the  so-called  subaponeurotic 
abscess : 

"One  must  hasten  to  make  two  incisions,  one  in  the 
palm  of  the  hand,  the  other  in  the  forearm,  connecting 
them  by  a  drainage  tube  which  passes  behind  the 
anterior  annular  ligament  of  the  wrist." 

Concerning  operation  when  a  diagnosis  of  extension 
into  the  forearm  is  made,  he  continues  as  follows:2 

"It  is  now  well  to  delay  no  longer  in  opening  the 
focus  extensively  without  waiting  for  the  fluctuation 
to  become  more  superficial.  In  reaching  the  skin  the 
pus  must  "invade  the  lower  layers  of  the  forearm  and 
also  the  radiocarpal  articulation. 

"In  making  this  opening  one  must  cut  through  the 
entire  thickness  of  the  antibrachial  region  and  '  manage ' 
the  important  organs  there  enclosed,  especially  the 
median  nerve.  Remember  that  this  nerve  is  placed 
slightly  without  the  axis  of  the  forearm;  consequently 
the  place  to  choose  for  the  opening  of  deep  abscesses 
of  the  wrist-joint  is  located  just  inside  the  median  line. 

"At  this  level  make  an  incision  about  4  to  5  cm. 
long,  and  successively,  layer  for  layer,  as  if  for  a  liga- 

1  Trait6  d  'Anatomic  topographique,  1887,  p.  572. 
2Traite  de  Chir.  clinique,   1897,  tome  i,  p.  674. 


V 

EXCERPTS  FROM  THE  LITERATURE  247 

ture  of  the  artery,  cut  through  all  the  soft  parts  of  the 
forearm  until  you  reach  the  focus. 

"  If  in  the  hand  there  be  a  focus  communicating  with 
that  of  the  wrist  below  the  anterior  annular  ligament 
of  the  wrist,  it  would  be  necessary  to  drain  it,  and  it 
might  be  even  necessary  to  make  another  opening." 

Farther  on  (pages  684  and  685)  he  not  only  continues 
to  show  a  lack  of  knowledge  of  the  anatomical  and 
pathological  condition  present,  but  advises  procedures 
which  should  be  condemned. 

"  Subaponeurotic  abscess.  The  abscess  must  be 
opened  from  the  palmar  face,  always  remembering  that 
the  superficial  palmar  arch  lies  in  a  transverse  line, 
beginning  at  the  root  of  the  thumb.  One  should,  at 
the  same  time,  open  the  abscess  from  the  dorsal  side 
and  establish  thorough  drainage. 

"If  necessary,  pass  another  drain,  joining  the  hand 
and  wrist  through  the  radiocarpal  canal.  Long  car- 
bolic baths  should  be  given." 

Konig1  speaks  for  early  and  large  incisions,  strong 
antiseptics  (5  per  cent,  carbolic  acid),  drainage,  suit- 
able position  of  the  hand  and  finger  inside  the  bandage, 
vertical  suspension  of  the  arm,  excision  of  the  arm, 
excision  of  the  necrotic  tendon,  but  only  after  a  true 
loosening  has  taken  place. 

"But  even  when  the  tenovaginitis  has  persisted  for 
a  long  time,  if  the  abscesses  have  formed  along  the 
forearm  with  suppuration,  much  may  be  accomplished 
with  antiseptic  treatment.  Here,  too,  it  is  a  question, 
after  one  or  two  days  of  suspension,  to  stop  the  swell- 
ing, of  extensive  opening  of  the  abscesses  and  drainage, 
to  introduce  a  number  of  small  pieces  of  a  drain  into 
the  abscess  openings.  Then  all  the  abscesses  are  dis- 
infected in  the  manner  described  above  and  an  anti- 
septic bandage  applied  (iodoform).  If  one  succeeds 

1  Speciale  Chirurgie,  vol.  iii,  pp.  369,  370. 


248     TREATMENT  OF  SVPPVRATIVE  TENOSYNOVITIS 

in  this  wise  in  mastering  the  progress  of  the  disease, 
then  usually  permanent  irrigation  with  salicylic  acid 
will  work  admirably. 

"Large,  widespread  incisions  are  to  be  recommended 
under  such  circumstances,  and  one  should  not  hesitate 
to  do  as  Helferich  has  already  suggested,  under  special 
conditions  to  cut  through  the  transverse  ligament. 
Helferich  recommended  that  after  so  extensive  an 
incision  the  ligament  and  the  wound  should  soon  be 
closed  with  a  secondary  suture,  if  the  phlegmon  is 
receding." 

The  use  of  strong  antiseptics,  particularly  5  per  cent, 
carbolic  acid,  as  suggested  by  Konig,  has  been  almost 
entirely  abandoned.  It  is  recognized  now  that  these 
antiseptics  certainly  impair  the  physiological  function 
of  the  cells  and  probably  do  as  much  harm  as  good. 

E.  Lexer1  says: 

"Good  results  may  be  obtained  only  by  as  early 
and  as  long  an  incision  as  possible." 

B.  Tillmans2  says: 

"In  light  cases  one  treats  an  acute  non-suppurative 
carpal  bursitis  by  a  high  vertical  position  on  a  splint, 
and  ice.  If  improvement  does  not  follow,  if  suppura- 
tion threatens,  or  if  it  has  already  started,  one  should 
open  the  synovial  sac  by  extensive  incisions  above  and 
below  the  anterior  annular  ligament,  drain  it  and  apply 
an  aseptic  bandage,  preferably  with  a  higher  vertical 
position  on  the  suspension  splint,  according  to  von 
Volkmann.  Strict  precautions  should  be  taken  against 
an  extension  of  the  suppuration,  for  example,  to  the 
forearm." 

P.  L.  Friedrich3  expresses  himself  as  follows: 

"If  the   inflammatory   process   finally  extends   up- 

1  Speciale  Chirurgie,  1902,  s.  726. 

2  Lehrbuch  der  speciellen  Chirurgie,  1901. 

3  Von  Bergmann,  v.  Bruns,  v.  Mikulicz,  Handbuch  der  praktischen  Chirur- 
gie, 1901,  vol.  iv,  p.  420. 


EXCERPTS  FROM  THE  LITERATURE  249 

ward  under  the  carpal  ligament  and  in  the  manner 
just  described  reaches  the  subfascial  muscular  inter- 
stices of  the  arm,  the  only  advice  one  can  give  is  to  go 
down  with  knife  and  dressing  forceps  into  each  sus- 
pected focus  of  infection,  with  careful  consideration  of 
the  nerves  and  vessels,  and  to  drain  effectually  with 
a  not  too  thin  drainage  material  which  will  not  be 
pasted  together  by  taut  portions  of  the  tissue.  If  it 
is  not  possible  to  guarantee  the  outflow  of  the  pus  in 
a  short  time  to  such  an  extent  in  the  region  of  the 
transverse  ligament,  consideration  of  the  danger  to 
the  carpal  joints  demands  the  cutting  of  the  transverse 
ligament  (Helferich,  Konig)." 

Friedrich's  article  demonstrates  that  even  at  the 
present  time  there  is  a  tendency  to  blind  dissection 
in  these  cases.  The  same  may  be  said  of  the  articles 
appearing  in  the  later  symptoms  of  surgery  emanating 
from  American  authors. 

P.  Mauclaire,1  in  a  similar  French  system  of  surgery 
(we  find  a  very  similar  description  by  Lyot),  gives  the 
following  description  of  treatment: 

"As  for  the  subaponeurotic  abscess,  if  it  is  a  ques- 
tion of  deep  lymphangitis,  or  of  suppurative  synovitis, 
the  incision  should  be  made  where  there  is  fluctua- 
tion, and  the  region  drained,  it  being  possible  for  the 
same  drain  to  go  from  the  palmar  region  to  the  anti- 
brachial  region.  In  making  this  incision  one  should 
guard  the  bloodvessels,  the  nerves,  and  the  tendons. 
One  often  finds  a  focus  of  suppuration  in  the  forearm, 
in  the  median  line  in  front  of  the  pronator  quadratus, 
or  sometimes  between  this  muscle  and  the  inter- 
osseous  membrane. 

"To  open  this  focus,  one  should  make  an  incision 
either  on  the  centre  of  the  anterior  face  of  the  wrist 
along  the  inner  edge  of  the  palmaris  longus,  or  longi- 

1  Dentu  et  Delbert,  Trait£  de  Chirurgie,  1901,  tome  x,  and  tome  iii,  p.  850. 


250     TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 

tudinally  along  the  internal  border  of  the  wrist;  by 
approximately  following  the  anterior  face  of  the  ulna, 
one  makes  a  path  between  the  deep  flexor  and  the 
pronator  quadratus  (Parona)." 

F.  Lejars1  gives  the  following  advice  for  the  treat- 
ment of  deep  phlegmon  of  the  hand : 

"One  must  open  the  palm,  the  great  palmar  sheath 
then  above  the  wrist,  incise  the  superior  extension,  the 
antibrachial  cul-de-sac  of  the  abscess;  and  last  from 
one  opening  to  the  other  pass  a  drain.  An  operation, 
indeed,  a  difficult  operation  in  such  a  position,  yet 
an  operation  of  immediate  urgency,  if  one  wants  to 
save  this  hand.  This  done,  place  the  member  in  a  con- 
tinuous bath,  leave  it  for  hours  in  the  liquid,  which 
one  renews  from  time  to  time  to  keep  the  temperature 
the  same.  This  will  be  the  best  after-treatment  of 
the  operation  which  you  have  just  made." 

Lejars'  procedure  is  one  that  can  be  carried  too 
far,  since  the  development  of  granulation  tissue  may 
be  excessive,  and  in  my  opinion  the  treatment  should 
be  abandoned  after  twenty-four  to  forty-eight  hours, 
when  the  process  is  found  to  have  come  to  a  standstill. 
After  that  the  hot  bath  may  be  used  at  the  time  of 
dressing  only. 

In  a  treatise  on  the  treatment  of  serious  phlegmons, 
delivered  in  the  Naturforscherversammlung  in  Halle,2 
1891,  Helferich,  of  Griefswald,  explains  his  methods  as 
follows:  As  example,  he  takes  a  phlegmon  of  the  hand 
and  forearm,  resulting  from  a  penetrating  injury  to 
the  little  finger,  and  emphasizes  that  such  a  case,  as 
well  as  a  crushed  fracture,  should  be  opened  as  quickly 
as  possible  to  prevent  the  spreading  and  further 
resorption  of  the  poisonous  matter  and  the  inflam- 
matory disturbances  of  tendons  and  connective  tissue. 

1Traite  de  chirurgie  d'urgence,  Paris,  1901. 

2  Berliner  klinischen  Wochenschrift,  1892,  No.  4. 


EXCERPTS  FROM  THE  LITERATURE  251 

'GO-  ifeE    '        OGTEGFA-THr 

"After  the  usual  preparations  for  the  operation 
(bath,  deep  narcosis,  cleaning  of  the  operative  field, 
application  of  Esmarch's  bandage),  he  makes  an  ex- 
tensive incision  at  the  point  of  infection,  that  is,  for 
example,  on  the  little  finger,  which  runs  to  the  side  of 
the  flexor  tendon  longitudinally.  An  assistant  care- 
fully draws  apart  the  edges  of  the  wound,  which  are  at 
first  only  slightly  gaping,  with  two  little  hooks.  If 
the  suppurative  channel  is  opened  either  beside  or 
within  the  tendon  sheath,  the  careful  introduction  of 
a  sound  serves  to  control  the  direction  of  the  knife 
and  scissors.  And  so  the  preparations  having  been 
made,  one  continues  the  incision  further  into  the  palm 
of  the  hand,  sparing  only  the  tendons,  nerves,  and 
large  vessles,  through  the  anterior  annular  ligament 
over  the  volar  side  of  the  forearm.  Here,  in  case  of  a 
phlegmon  extending  from  the  little  finger,  one  keeps 
to  the  ulnar  side  of  the  common  flexors,  continuing 
upward,  the  region  having  been  prepared  below.  If 
it  is  a  question  of  a  phlegmon  on  the  thumb  side  of 
the  hand  and  the  radial  side  of  the  forearm,  one  would 
proceed  accordingly,  but  following  the  same  principles. 
The  object  is  complete  exposure  of  the  suppurative 
foci  and  the  prevention  of  the  infiltration  of  pus  into 
the  intermuscular  layers  of  connective  tissue.  Often 
enough  a  focus  somewhat  encapsulated  by  the  sticking 
together  of  the  edges  is  found  between  the  muscles, 
and  even  under  the  flexor  profundus  digitorum,  so 
that  the  interosseous  membrane  is  widely  laid  open. 
Upward  the  incision  first  comes  to  an  end  when  a 
thorough  examination  of  the  tissue  and  the  palpation 
of  the  adjoining  region  leads  one  to  expect  healthy 
conditions. 

"So  far  as  necessary,  other  incisions  are  added  to 
this  large  one,  either  on  the  other  side  of  the  palm  or 
on  the  dorsal  side." 


252    TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 


He  is  decidedly  ;against  any  other  treatment  of  this 
process,  and  has  never  seen  any  good  results  from 
small  punctures;  small  incisions  and  drainage  cannot 
effect  nearly  as  much.  Disinfection  of  the  wound  is 
dispensed  with,  and  he  confines  himself  to  a  careful 
washing  out  with  a  6  per  cent,  salt  solution,  empha- 
sizing the  local  injuries,  irritating  effect  of  antiseptics 
and  the  very  unfavorable  effect  of  the  same  on  the 
kidneys. 

In  the  after-treatment  he  emphasizes  passive  move- 
ments, baths,  active  movements  in  water-baths,  mas- 
sage, electricity,  occasional  compression,  and  nightly 
fixation  in  various  positions. 

Helferich  then  recommends  an  apparatus  invented 
by  Dr.  Krukenberg  for  the  development  of  passive 
movements. 

C.  L.  Schleich1  says  in  speaking  of  the  treatment  of 
phlegmons  of  the  palm  of  the  hand : 

"If  we  cut  through  the  ligament  we  can  prepare  for 
the  most  serious  functional  disturbances ;  if,  on  the  other 
hand,  we  do  not  follow  up  the  channel  of  suppuration 
we  leave  a  great  mortal  danger.  To  decide  this  matter 
we  press  firmly  on  the  tendinous  convolutions  above 
the  ligament  of  the  forearm  and  pressing  out  the  con- 
tents toward  the  periphery;  we  will  suppose  that  no 
drop  of  pus  flows  from  the  tendon  pocket  below  the 
ligament.  We  are  then  obliged  to  make  a  counter- 
opening  above  the  ligament,  which  would  have  been 
absolutely  necessary  in  the  presence  of  pus  above  the 
same.  I  depend  on  the  appearance  of  this  super- 
ligamentary  flexor  swelling  to  decide  whether,  through 
a  counter-opening,  I  shall  pass  a  drain  of  gauze  strip 
under  the  ligament,  or  whether  I  shall  cut  through  the 
ligament  to  further  lay  bare  the  avenues  of  infection. 
In  case  of  dry  opacity  and  scarring,  I  usually  let  gauze 

1  Neue  Methoden  der  Wundheilung,  Berlin,  1899. 


EXCERPTS  FROM  THE  LITERATURE  253 

drainage  suffice ;  if,  however,  fluid  pus  is  found  between 
the  tendons,  I  stand  for  unconditional  severing  of 
the  ligament  and  further  following  up  the  avenues  of 
infection. " 

K.  Poulsen  (quoted  from  Forssell)  gives  the  follow- 
ing description  of  the  opening  of  the  ulnar  tendon 
sheaths : 

"If  the  sheath  is  swollen,  or  the  skin  edematous, 
it  is  not  so  easy  to  see  what  one  is  about  or  to  say 
exactly  what  flexor  tendon  lies  before  him  while  he 
is  making  the  incision;  yet  in  these  cases  it  is  of  no 
great  importance  if  one  should  happen  to  get  in  between 
the  deep  flexor  tendons  of  the  second  and  third  fingers ; 
the  sheath  when  it  is  stretched  is  always  opened,  if 
one  only  gets  in  between  the  tendons  of  the  deep 
flexor  muscles.  The  incision  is  then  made  in  the  follow- 
ing manner:  The  arm  is  rendered  bloodless,  and  then 
one  determines  the  position  of  the  M.  flexor  ulnaris 
with  the  help  of  the  os  pisiforme,  its  point  of  insertion, 
and  of  the  tendon  of  the  M.  flexor  carpi  radialis  by 
drawing  a  line  upward  from  the  second  metacarpal 
joint,  to  whose  base  it  is  attached.  Half-way  between 
these  two  tendons  an  incision  is  made  to  the  liga- 
mentum  carpi  volare  proper;  hooks  are  used  to  widen 
the  wound,  with  the  radial  (side)  one  must  be  very 
careful  on  account  of  the  median  nerve.  Next,  he 
proceeds  into  the  depth  between  the  tendons,  first 
the  superficial  ones,  then  the  deep-lying  ones;  when 
the  connective  tissue  which  binds  together  the  deep 
tendons  has  been  passed,  the  sheath  is  opened,  the  pus 
streams  out,  while  with  a  Lister 's  forceps  the  opening 
of  the  sac  is  dilated  upward  and  downward ;  after  this 
iodoform  gauze  is  laid  in,  the  bandage  removed,  and 
the  bleeding  stopped  by  compression. 

"As  a  bandage  I  usually  use  a  boric  acid  applica- 
tion which  is  changed  daily.  The  gauze  remains  undis- 


254     TREATMENT  OF  SUPPURATIVE   TENOSYNOVITIS 

turbed  until  it  loosens  of  itself;  and  as  a  support  for 
the  hand,  a  volar  splint  is  used.  Some  prefer  to  make 
an  opening  upon  a  bulb-headed  probe  previously  in- 
troduced in  the  vola  manus  on  the  lower  border  of  the 
ligamentum  carpi  volare  proper,  and  to  draw  a  drain 
in  between  the  two  openings.  Yet  I  must  say  that  I 
have  no  particular  fondness  for  using  drains  in  this 
place,  as  they  easily  compress  the  tendons  in  this 
comparatively  narrow  canal  and  thereby  give  rise 
to  necrosis.  If  the  incision  has  been  made  above  the 
ligament,  and  along  the  tendon  to  the  little  finger, 
there  will  be  an  upper  and  lower  opening  of  the  bursa, 
which,  without  danger  to  the  tendons,  can  be  held 
open  by  gauze  drainage,  and  offers  sufficient  outlet 
for  the  pus,  at  least  so  long  as  the  pus  confines  itself  to 
the  sheath  alone.  If  the  suppuration  lasts  I  prefer 
to  split  the  ligamentum  carpi  volare  proper  and  lay 
open  the  canals;  it  is  not  rare  to  succeed  in  this  way 
in  rescuing  the  tendons  which  at  this  point  have  a 
fairly  large  vessel  lying  in  mesotendon. " 

K.  Poulsen  has  also  discussed  the  therapeutics  of 
tendovaginitis  of  the  thumb  and  radial  bursa.  He 
opens  the  finger  tendon  sheath  to  the  lower  edge  of 
the  M.  adductor  pollicis  and  the  radial  bursa  above 
the  ligament,  avoids  drainage  tubes,  and  in  their  place 
uses  gauze  drainage. 

"In  cases  of  persistent  suppuration  the  ligament  is 
cut  and  a  peritendinous  phlegmon  is  mastered  by 
continuing  the  incision  on  the  thumb  along  the  lower 
border  of  the  abductor,  and  laying  in  drains  when  it 
is  seen  that  the  tendon  will  be  lost;  the  cutting  through 
of  the  muscular  system  of  the  thenar,  used  by  some, 
should  be  resorted  to  only  in  desperate  cases,  because 
it  destroys  in  large  measure  the  function  of  the  ab- 
ductor. " 

It  would  seem  from  this  that  Poulsen,  at  least  in 


EXCERPTS  FROM  THE  LITERATURE  255 

coincident  infections  of  the  tendon  sheath  of  the  thumb 
and  the  radial  bursa,  opens  the  latter  only  above  the 
ligament,  and  exposes  that  part  of  the  bursa  which 
lies  within  the  thenar,  only  when  the  suppuration  has 
spread  beyond  the  bursa.  In  cases  of  persistent  sup- 
puration the  ligament  is  cut;  but  he  does  not  state 
whether,  after  this  tardy  fissure  of  the  ligament,  he  has 
found  the  flexor  tendon  of  the  thumb  and  the  thenar 
nerves  capable  of  carrying  on.  their  work  or  not. 

"Why  it  should  ever  be  necessary  to  split  the  thenar 
muscles  after  cleaving  the  ligament  I  cannot  see,  as 
only  a  small  upper  point  covers  the  radial  bursa  below 
the  ligament.  Nor  is  it  clear  why  such  a  fissure  of 
the  muscles  in  question  should  destroy  a  great  part 
of  their  functional  activity;  but  the  incision,  continued 
through  the  ligaments  and  all  the  soft  parts,  including 
the  tendon  sheath,  cuts  through  the  nerves,  not  only 
of  the  M.  adductor,  but  also  of  the  M.  opponens  and 
of  the  superficial  part  of  the  M.  flexor  brevis,  and  thus 
causes  a  very  troublesome  crippling  of  the  thumb. 

"Finally,  to  use  this  method  of  operation  in  'des- 
perate' cases  will  not  save  the  tendon  of  the  thumb; 
it  is  undoubtedly  better  to  remove  the  tendon,  which 
in  such  a  case  would  undoubtedly  be  destroyed  or 
rendered  useless  at  this  late  date." 

To  open  the  upper  end  of  the  radial  bursa,  Max 
Schiiller  proceeds  as  follows:  The  incisions  are  best 
made  outward  (toward  the  radial  side)  on  the  forearm, 
beginning  at  the  radial  artery  and  extending  along  it. 

Nicaise,  on  the  other  hand,  places  the  incision 
between  the  arterioradialis  and  the  tendon  of  the 
M.  flexor  carpi  radialis,  and  between  the  latter  and 
the  tendon  of  the  M.  palmaris  longus. 


CHAPTER    XVI. 

THE  TREATMENT  OF  ACUTE  SUPPURATIVE 

TENOSYNOVITIS— DISCUSSION  OF 

TECHNIQUE. 

FOLLOWING  the  anatomical  investigations  detailed 
in  the  previous  chapters  and  a  careful  study  of  all 
clinical  cases  coming  under  observation,  certain  pro- 
cedures were  instituted,  which  in  my  hands  have  given 
most  satisfactory  results.  The  technique  which  I 
have  used  in  these  serious  cases  is  herewith  described. 
This  may  be  classified  under  three  heads. 

1.  In  the  early  hours  while  the  diagnosis  may  be 
in  doubt. 

2.  When  the  symptoms  and  signs  of  tenosynovitis 
are  marked. 

3.  After-treatment. 

TREATMENT    WHILE    THE    DIAGNOSIS    MAY    BE    IN    DOUBT. 

Very  commonly,  when  a  finger  is  infected,  it  is  some 
days  before  the  tendon  sheath  becomes  involved; 
again,  it  may  be  early,  and  when  it  is  invaded  the 
symptoms  develop  rapidly  because,  as  was  mentioned 
above,  there  is  so  little  resistance  that  the  infection 
spreads  throughout  the  sheath  in  a  short  time.  How- 
ever, during  the  preliminary  stage,  much  may  be  done 
to  prevent  a  spread  into  the  sheath.  The  best  sort 
of  application  is  undoubtedly  some  form  of  moist,  hot 
dressing.  Boric  acid  solution  in  saturated  strength  is 
most  commonly  used,  but  any  of  the  other  solutions 
in  common  use  are  probably  just  as  efficient.  Carbolic 
acid  dressing  in  any  form  should  be  avoided  because  of 


TECHNIQUE  OF  TREATMENT  AFTER  DIAGNOSIS     257 

the  danger  of  gangrene.  Local  painting  with  ichthyol, 
iodine,  and  such  irritating  solutions  is  absolutely  use- 
less. German  surgeons  speak  highly  of  95  per  cent, 
alcohol  dressings  left  on  twenty-four  hours.  They 
probably  are  no  more  efficient  than  the  hot  boric 
solution,  and  are  always  a  source  of  some  anxiety, 
owing  to  the  possible  danger  of  their  catching  fire,  as 
I  have  personal  knowledge  of  in  one  case.  Probably 
the  next  most  essential  procedure  is  to  keep  the  part 
at  rest;  this,  of  course,  is  indicated  in  any  infection, 
since  the  muscular  action  tends  to  disseminate  the 
germs,  thus  extending  the  area  to  be  walled  off  by  the 
leukocytes  carried  in  by  the  dilatation  of  the  vessels 
incident  to  the  hot  dressings.  Elevation  of  the  parts 
is  recommended  by  many,  but  personally  I  could  never 
see  any  advantage  in  it  except  to  make  the  arm  com- 
fortable, and  it  is  true  the  elevation  of  the  hand  is 
sometimes  necessary  for  this.  If  the  infection  is  severe, 
put  the  patient  in  bed.  An  ice-bag  in  the  axilla  may 
help  some.  Keep  the  bowels  open  and  the  kidneys 
active.  Preserve  the  nutrition  of  the  patient.  The 
methods  of  Bier  and  Klapp  are  discussed  above. 

TECHNIQUE  OF  TREATMENT  AFTER  DIAGNOSIS  IS  MADE. 

The  diversity  of  opinions  as  to  the  proper  methods 
of  treatment  held  by  various  surgeons,  as  noted  above, 
is  sufficient  proof  of  the  severity  of  this  condition  and 
the  difficulty  of  its  treatment.  It  emphasizes  the  fre- 
quency of  bad  functional  results  and  should  stimulate 
us  to  most  careful  study  of  our  cases. 

The  diagnostic  acumen  of  the  operator  cannot  but 
be  a  vital  factor  in  the  treatment.  It  is  probable  that 
too  many  will  err  on  the  side  of  conservatism  in  the 
treatment  of  the  first  cases  that  are  met.  It  will  be 
reasoned  that  since  some  damage  already  will  have 
17 


occurred  to  the  tendons,  if  they  are  involved,  a  few 
hours'  delay  will  not  add  seriously  to  the  condition. 
This  possibility  will  be  preferred  to  that  of  opening  and 
infecting  an  uninvolved  sheath.  However,  these  few 
hours  are  of  great  importance  in  the  fulminating  type, 
and  operation  should  be  most  prompt. 

I  do  not  intend  this  as  advocacy  of  operation  regard- 
less of  accurate  diagnosis,  but  as  a  stimulus  to  careful 
study  to  the  end  that  the  surgeon,  being  better  qualified, 
may  neither,  by  ill-advised  conservatism,  delay  neces- 
sary operation,  nor  by  thoughtless,  audacious  incisions 
jeopardize  the  usefulness  of  a  healthy  hand. 

My  own  opinions  as  to  the  best  methods  are  based 
upon  my  anatomical  researches  and  upon  observation 
of  the  patients  presenting  themselves  at  the  dispensary 
and  hospital  of  the  Post-Graduate  Medical  School  and 
Hospital,  at  Wesley  Hospital,  and  the  Northwestern 
University  Medical  School.  To  Professors  Besley  and 
Richter,  and  others  of  my  friends  at  these  hospitals 
and  at  the  Cook  County  Hospital,  I  wish  to  acknowl- 
edge my  appreciation  of  the  opportunity  for  the  study 
of  their  cases  in  addition  to  my  own.  Concerning  the 
technique  of  treatment,  I  cannot  help  but  feel  that 
the  future  has  much  in  store  for  us  that  we  cannot 
know  at  the  present  time.  The  subject  is  one  not  only 
of  local  condition,  but  of  the  resistance  of  the  individual 
and  his  reaction  to  various  toxins.  In  other  words, 
the  newer  problems  in  serum  pathology  must  first  be 
worked  out  before  we  can  attain  the  best  results.  I 
cannot  but  feel,  however,  that  even  the  local  conditions 
are  not  so  well  understood  by  the  average  surgeon  as 
is  possible,  and  that  our  bad  results  would  be  reduced 
at  least  by  half  if  more  study  were  given  to  careful 
diagnosis. 

I  have  secured  the  best  results  by  the  following 
procedures.  Operation  should  always  be  done  under 


TREATMENT  OF  TENOSYNOVITIS  OF  FINGERS     259 

general  anesthesia  and  in  a  bloodless  field.  Where  the 
process  is  especially  virulent  and  acute,  I  leave  on  the 
Esmarch  bandage  for  twelve  to  eighteen  hours  after 
the  operation.  Care  is  taken,  however,  to  loosen  it  so 
as  to  produce  a  passive  hyperemia.  In  other  words,  a 
Bier's  hyperemia  is  secured  for  this  time.  This  is 
done  not  so  much  for  the  therapeutic  effect  as  to  prevent 
the  rapid  absorption  of  virulent  toxins.  I  hope  in  this 
manner  to  give  the  patient  time  to  react  and  develop 
antitoxins  to  overcome  the  poison  rather  than  allow 
him  to  be  overwhelmed  by  a  large  amount  of  virulent 
toxin  absorbed  at  one  time. 

TREATMENT  OF  TENOSYNOVITIS  OF  THE  INDEX,  MIDDLE,  AND 

RING  FINGERS. 
/ 

The  procedure  will  vary  according  to  the  form  of 
infection  and  the  amount  of  destruction  present.  The 
first  incision  is  made  at  the  site  of  known  infection, 
opening  the  sheath  at  the  side  and  not  in  the  median 
line,  cutting  the  length  of  the  shaft  of  the  proximal  or 
middle  phalanx,  and  leaving  the  part  over  the  articula- 
tion uncut  so  that  the  tendon  does  not  prolapse,  unless 
there  is  doubt  as  to  the  freedom  of  drainage.  I  wish 
to  insist  that  the  first  requisite  is  adequacy  of  the  open- 
ing for  drainage,  since  a  small  incision  soon  becomes 
closed  by  prolapsing  tissue.  Make  the  incision  too 
free  rather  than  too  small.  In  those  cases  where  it  has 
seemed  advisable  to  incise  the  length  of  the  sheath, 
which  I  do  in  case  of  doubt,  I  have  bound  the  finger 
in  an  extended  position  to  prevent  prolapse  of  the 
tendons.  After  having  opened  the  sheath  at  this  one 
point,  pressure  upon  its  various  parts  will  give  one 
some  idea  of  the  extent  of  the  invasion.  If  it  is  com- 
plete, as  is  generally  the  case,  a  similar  incision  is  made 
over  the  uncut  proximal  or  middle  phalanx.  No 
incision  is  necessary,  as  a  rule,  over  the  distal  phalanx, 


260     TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 


and  in  making  this  I  feel  that  Klapp  is  in  error  if  his 
drawing  represents  his  technique  correctly.  Over  the 
proximal  end  of  the  sheath,  at  the  base  of  the  palm, 
the  technique  will  vary  according  to  the  extent  of  the 
invasion.  If  early,  the  incision  is  made  over  the  middle 
of  the  sheath  at  its  end  in  the  palm,  carrying  it  from 
the  flexion  crease  at  the  base  of  the  proximal  phalanx 
for  about  three-fourths  of  an  inch  into  the  palm.  If, 
however,  there  is  some  question  whether  the  lumbrical 
spaces  at  the  sides  have  begun  to  become  involved 

FIG.  87 


Lines  show  area  of  possible  incisions  for  infections  of  the  various  tendon 
sheaths.     (See  text  for  full  description.) 

(vide  supra),  the  incision  is  made  upon  the  side  most 
affected,  opening  the  space  and  the  tendon  sheath 
at  the  same  time.  If  both  sides  are  involved,  two 
incisions  are  made.  The  finger  is  now  cleansed  and 
examined.  If  the  amount  of  pus  is  great,  a  second  line 
of  incisions  is  made  upon  the  opposite  side  of  the 
finger  over  the  two  proximal  phalanges  by  inserting 
the  knife  blade  through  from  the  incision  already  made 
on  the  one  side  (Fig.  87).  If  there  is  much  involve- 
ment of  the  synovial  surfaces,  or  if  there  is  much 


TREATMENT  OF  TENOSYNOVITIS  OF  FINGERS     261 

edema  of  the  finger,  which  would  tend  to  close  the 
incisions,  I  connect  the  two  first  incisions  made,  thus 
making  one  incision  the  length  of  the  finger  rather  than 
multiple  incisions  on  both  sides  of  the  finger. 

I  have  tried  cutting  down  to  the  sac  in  doubtful 
cases,1  then  inserting  an  aspirating  needle  and  attempt- 
ing to  draw  off  some  pus  for  diagnostic  purposes, 
hoping  by  this  procedure  to  avoid  the  possibility  of 
infecting  an  uninvolved  sheath  through  opening  it  with 
a  scalpel.  While,  theoretically,  the  procedure  would 
appear  to  be  advisable,  practically  it  is  of  little  aid. 
The  bulging  of  the  sheath,  proving  the  presence  of 
fluid  under  tension,  is  generally  easily  seen,  while  a 
failure  to  secure  pus  is  not  sufficient  evidence  of  its 
absence. 

WHEN  THE  INVOLVEMENT  OF  ADJACENT  AREAS  HAS 
BEGUN. — The  involvement  of  the  articulation  between 
the  middle  and  proximal  phalanges,  which  occurs  in 
late  cases,  will  be  discussed  in  the  chapter  dealing  with 
complications  and  sequelae  (Chapter  XXVIII).  The 
method  of  treatment  will  be  outlined  there.  I  shall 
only  add  to  what  I  have  already  said,  that  if  early 
incision  of  the  sheath  is  made  this  involvement  is 
generally  prevented:  another  reason  for  early  incision. 
As  has  been  pointed  out,  the  paths  of  extension  in 
the  involvement  of  the  lumbrical  spaces  vary  in  the 
individual  fingers. 

The  Index  Finger. — When  the  infection  passes  to 
the  lumbrical  space  on  the  outer  side,  it  may  extend 
into  the  thenar  space,  and  the  incision  which  opens  the 
lumbrical  space  can  extend  up  into  the  thenar.  Press- 
ure upon  the  thenar  area  will  force  pus  out  along  the 
line  of  incision.  This  is  then  extended  along  the  radial 
side  of  the  metacarpal  bone,  the  incision  lying  dorsal 
to  the  web  which  extends  from  the  thumb  to  .the  base 

1  White,  Whitlow  and  its  Treatment,  Brit.  Med.  Jour.,  February  24,  1906. 


262     TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 

of  the  index  finger.  The  artery  forceps  is  then  carried 
across  the  palmar  surface  of  metacarpal  bone  and  the 
blades  opened,  thus  draining  the  thenar  space  without 
an  incision  upon  the  palmar  surface  (Figs.  100  and  106). 
Care  should  be  used  not  to  force  the  point  of  the  for- 
ceps beyond  the  middle  metacarpal  bone;  otherwise  the 
middle  palmar  space  will  be  entered  and  an  extension 
to  this  space  favored. 

When  the  extension  has  entered  the  lumbrical  space 
between  the  index  and  middle  finger,  the  incision  should 
be  made  into  the  sheath  at  its  ulnar  side,  thus  opening 
both  the  sheath  and  the  lumbrical  canal  through  the 
same  skin  incision.  If  the  lumbrical  canal  is  badly 
involved,  the  pus  may  have  extended  distally  into  the 
loose  mesh  of  tissue  at  the  web  or  proximally.  If 
distally,  it  may  be  necessary  to  add  a  second  incision 
upon  the  dorsum  between  the  bases  of  the  index  and 
middle  fingers,  and  procure  through-and-through  drain- 
age of  the  web,  or  at  times  I  have  split  the  web  com- 
pletely and  have  not  as  yet  observed  any  serious 
impairment  of  function  following  (Fig.  106). 

If  the  infection  extends  proximally,  some  care 
should  be  used  in  the  incision,  since  it  may  extend 
either  into  the  thenar  or  middle  palmar  spaces.  After 
the  lumbrical  canal  is  opened,  pressure  over  these 
areas  will  demonstrate  which  is  involved,  since  pus  will 
exude  into  the  incision.  The  incision  is  then  extended 
upon  a  grooved  director  along  the  line  of  invasion,  cut- 
ting about  one-fourth  of  an  inch  proximal  to  the  line 
joining  the  ends  of  the  flexion  creases  at  the  distal 
part  of  the  palm ;  an  artery  forceps  is  thrust  under  the 
tendon  into  the  space,  which,  by  separating  the  blades, 
is  effectually  opened.  We  frequently  find  invasion  of 
the  thenar  area  either  directly  from  the  sheath  or 
secondarily  by  way  of  the  lumbrical  canals;  when  this 
occurs  I  supplement  this  palmar  incision  by  one  upon 


TENOSYNOVITIS  OF   FINGER  AND    ULNAR  BURSA     263 

the  dorsal  surface  between  the  metacarpal  bones  of 
the  thumb  and  index  finger,  i.  e.,  drainage  of  the 
thenar  space  as  described  in  Chapter  XVII. 

The  Middle  Finger. — When  extension  occurs  into  the 
lumbrical  canal  upon  the  radial  side,  or  the  web  on 
either  side,  the  technique  of  treatment  is  that  just 
described.  When  the  extension  is  along  the  lum- 
brical canal  between  the  middle  and  ring  fingers 
toward  the  palm,  early  the  pus  may  be  between  the 
palmar  fascia  and  the  tendon  in  the  "loft,"  as  already 
described,  but  it  very  soon  involves  the  middle  palmar 
space.  Here  the  incision  is  carried  one-quarter  inch 
into  the  palm,  i.  e.,  proximal  to  the  transverse  line 
joining  the  ends  of  the  flexion  creases.  If  pus  is  ex- 
pressed through  this  from  the  palm,  an  artery  forceps 
is  inserted  under  the  tendons  going  to  the  ulnar  side 
and  the  blades  opened.  No  drainage  is  inserted,  al- 
though in  a  few  instances  I  have  placed  in  the  pocket 
small  strips  of  gutta-percha  or  gauze  thoroughly  im- 
pregnated with  vaseline.  Ordinary  gauze  acts  simply 
as  a  plug,  and  I  never  use  it. 

The  Ring  Finger. — Here  the  extension  to  the  web 
or  into  the  palmar  space  from  either  side  is  treated  by 
the  same  technique  as  described  above. 

TREATMENT  OF  TENOSYNOVITIS  OF  THE  LITTLE  FINGER  AND 
ULNAR  BURSA. 

If  the  finger  alone  is  involved,  the  treatment  is  the 
same  as  that  noted  above  for  the  other  fingers,  except 
that  almost  always  it  will  be  found  advisable  to  make 
a  single  incision  on  the  lateral  surface  the  length 
of  the  two  proximal  phalanges,  since  we  wish  to 
procure  perfect  drainage,  and  thus  avoid  possible 
extensions.  In  about  half  of  the  cases  there  is  a 
congenital  separation  of  the  proximal  from  the  distal 
portion  at  approximately  the  metacarpophalangeal 


264     TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 

articulation,  and  in  a  certain  proportion  of  these  cases 
in  which  there  is  no  separation  the  opening  is  so  nar- 
rowed that  there  is  a  temporary  dam  produced  by 
serous  adhesions  if  the  inflammation  is  not  too  ful- 
minating in  character,  which  unfortunately  it  generally 
is.  In  the  former  condition  there  is  little  likelihood 
of  a  spread  to  the  ulnar  sheath,  so  that  we  should  be 
extremely  careful  not  to  open  this  sheath  unless  we  are 
certain  that  it  has  become  infected,  since  we  are  ex- 
posing the  patient  to  grave  danger.  On  the  other  hand, 
if  the  occlusion  is  of  temporary  inflammatory  origin, 
we  can  readily  see  how  important  it  is  that  an  early 
diagnosis  of  the  condition  should  be  made  and  proper 
treatment  of  the  distal  portion  instituted  to  prevent  a 
spread  to  the  ulnar  sheath.  As  to  just  what  the  proper 
procedure  should  be,  in  case  we  are  fairly  certain  that 
there  is  an  infection  of  the  distal  portion  of  the  sheath 
and  we  are  still  in  doubt  as  to  whether  it  has  extended 
to  the  proximal  or  palmar  portion  or  not,  there  is  room 
for  discussion. 

Forssell  advises  that  we  should  begin  at  the  point 
where  we  are  least  sure  of  infection,  while  Helferich 
suggests  that  we  begin  at  the  point  of  infection  where  we 
are  sure  and  make  our  way  along  with  care.  Naturally, 
we  would  admit  the  former  to  be  the  proper  method 
if  certain  unknown  equations  did  not  enter  into  the 
discussion.  In  the  first  place,  what  proportion  of  aseptic 
ulnar  sheaths  can  be  opened  and  not  infect  the  sheath 
from  the  lymphatics  which  are  constantly  carrying 
germs  from  the  point  of  infection  through  the  subcu- 
taneous tissue  in  which  our  so-called  aseptic  incision 
is  made?  Upon  the  answer  to  this  question  depends  in 
all  probability  the  proper  solution  of  the  question,  and 
it  will  take  a  large  number  of  carefully  observed  cases 
to  arrive  at  a  decision.  Increasing  experience,  however, 
has  confirmed  me  in  the  opinion  that  it  is  wiser  to 


TENOSYNOVITIS  OF   FINGER  AND   ULNAR  BURSA     265 

incise  at  a  known  point  of  involvement.  This  pocket 
being  opened,  pressure  is  exerted  over  the  sites  of  pre- 
dilection in  continuity.  If  they  are  involved,  pus  will 
be  seen  to  enter  the  previously  opened  site.  A  grooved 
director  is  now  inserted  along  the  canal  and  the  incision 
continued  or  the  focus  opened  by  the  proper  methods. 

FIG.  88 


Lines  represent  the  various  incisions  made  for  infections  of  the  tendon 
sheaths  and  their  possible  extensions  into  the  forearm.  (See  text  for  com- 
plete description.) 

When  the  continuation  of  this  sheath  in  the  hand  is 
involved,  the  palmar  portion  is  opened  by  an  incision 
extending  from  the  base  of  the  finger  at  the  distal 
flexion  crease  of  the  palm  and  passing  toward  the  base 
of  the  palm  (Fig.  88).  It  is  my  custom  to  insert  a 
grooved  director  in  the  sheath  at  this  point  and  follow 
along  this,  cutting  the  tissues  between  the  sheath  and 
the  surface,  having  the  thought  in  mind  to  avoid  the 
tendon  and  cut  as  far  to  the  ulnar  side  of  the  sheath  as 
possible,  since  there  will  be  better  drainage,  particu- 
larly at  the  wrist,  if  this  is  done  (Fig.  89).  After  the 
anterior  annular  ligament  is  reached,  pressure  above 
over  the  prolongation  of  the  sheath  in  the  forearm  will 
force  pus  downward  into  the  sheath  below  the  ligament 
if  the  infection  has  extended  here,  as  it  generally  has. 

If  an  involvement  of  the  prolongation  of  the  sheaths 
above  the  annular  ligament  or  a  forearm  involvement 
is  diagnosticated,  I  proceed  as  follows.  At  a  point 


266     TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 


about  one  and  one-half  inches  above  the  tip  of  the  ulna 
an  incision  is  made  directly  down  on  this  bone  at  its 
flexor  surface,  an  artery  forceps  is  now  thrust  across 
the  flexor  surface  of  this  bone  and  the  radius  until 

FIG.  89 


ECU 


Cross-section  No.  VIII. — DSCS,  dorsal  subcutaneous  space;  EL,  extensor 
communis;  ECRB,  extensor  carpi  radialis  brevior;  ECRL,  extensor  carpi 
radialis  longior;  ECU,  extensor  carpi  ulnaris;  EMD,  extensor  minimi  digiti; 
EPTP,  extensor  primi  internodii  pollicis;  ESIP,  extensor  secundi  internodii 
pollicis;  FLP,  flexor  longus  pollicis  in  its  synovial  sheath;  HM,  hypothenar 
muscles  with  intermuscular  spaces;  MN  and  V,  median  nerve  and  vessels; 
PL,  palmaris  longus;  PMPS,  prolongation  middle  palmar  space;  RV  and  N, 
radial  vessels  and  nerves;  SS,  synovial  sheath;  TM,  thenar  muscles;  UB, 
ulnar  bursa;  UV  and  N,  ulnar  vessels  and  nerves.  The  ulnar  bursa,  radial 
bursa,  and  intermediate  sheaths  are  shown  in  red.  The  small  prolongation 
of  the  middle  palmar  and  thenar  spaces  in  blue. 

it  impinges  on  the  skin  at  the  radial  side,  where  the 
knife  cuts  down  upon  it.  The  incisions  in  the  skin  are 
now  enlarged  to  the  length  of  an  inch  and  one-half  or 
more  and  the  artery  forceps  opens  the  subtendinous 


TENOSYNOVITIS  OF   FINGER  AND   ULNAR  BURSA     267 

area  to  the  same  extent.  Make  the  incision  too  long 
rather  than  too  short,  since  a  large  incision  with  free 
drainage  will  heal  more  rapidly  than  a  small  incision 
with  inadequate  drainage.  Especial  care  should  be  used 
here  to  make  the  incision  neither  too  far  upon  the  flexor 
surface  nor  dorsally,  since  in  the  first  instance,  especially 
upon  the  radial  side,  the  artery  may  be  injured  either 
by  the  primary  incision  or  subsequent  necrosis;  and 
in  the  second  instance,  if  the  incision  is  too  far 
dorsal  it  will  not  drain  easily.  If  the  primary  incision 
is  made  low  down  and  on  the  radial  side  the  danger 
of  injuring  the  radial  is  greater.  With  the  proper 

FIG.  90 

m.n.     r.a. 


u.a. 
u.n. 


Cross-section  7  cm.  above  radial  styloid.  Artery  forceps  inserted  trans- 
versely in  juxtaposition  to  ulna  and  radius  through  the  anterior  interos- 
seous  space,  showing  that  incision  can  be  made  here  and  not  injure  important 
vessels  and  nerves.  Notice  tissue  between  radial  artery  and  the  forceps: 
r.  a.,  radial  artery;  u.  a.,  ulnar  artery;  u.  n.,  ulnar  nerve;  m.  «.,  median  nerve. 

precaution,  no  anxiety  need  be  felt  (Fig.  90).  Having 
opened  this  area,  the  finger  is  now  inserted  under  the 
flexor  profundus  tendons,  and  if  there  is  any  infection 
of  the  sheath,  it  is  bulging  and  can  be  opened  easily. 
In  case  it  is  not  found  easily,  flexion  and  extension  of 
the  fingers  will  locate  the  tendons  involved  and  the  pal- 
pating finger  can  be  pushed  up  among  them,  or  an 
artery  forceps  can  be  pushed  under  the  annular  liga- 
ment through  the  bursa  which  has  been  opened  in  the 
palm  in  front  (Fig.  91).  Its  point  is  felt  plainly  by 
the  finger  under  the  tendons,  and  the  opening  dilated 


268     TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 

freely.  As  a  matter  of  fact,  the  infection  will  be  found 
to  have  ruptured  into  this  space  in  practically  every 
case,  except  in  the  very  earliest  stages.  /  wish  to 
emphasize  that  it  is  upon  this  incision  that  I  depend  for 
drainage  of  the  upper  end  of  the  bursa,  since  it  extends 
upward  on  the  tendons  on  their  posterior  surface  (Fig. 
91).  In  other  words,  this  site  is  used  for  entering  and 
draining  the  sheath  before  rupture,  as  well  as  for 
incision  for  draining  the  extension  into  the  forearm. 
At  times  when  the  ulnar  bursa  alone  is  involved  the 

FIG.  91 


Drawing  showing  extension  of  the  ulnar  bursa  underneath  dorsal  surface 
of  the  flexor  tendons,  and  probe  inserted  from  a  palmar  incision,  passing 
under  the  anterior  annular  ligament  with  end  showing  in  the  ulnar  bursa 
above. 

incision  upon  the  ulnar  side  has  been  found  sufficient, 
and  I  shall  be  inclined  to  use  that  alone  in  the  future 
in  the  uncomplicated  cases.  It  will  be  remembered 
that  attention  has  already  been  drawn  to  the  fact  that 
when  extension  takes  place  this  area  between  the 
flexor  profundus  tendons  and  the  interosseous  septum 
and  the  pronator  quadratus  is  always  first  involved. 
In  the  early  stages  of  rupture,  after  having  cut  through 
the  skin  and  subcutaneous  tissue,  the  operator  will  be 
inclined  to  desist,  since  no  evidence  of  pus  will  be  found. 
It  is  not  until  the  area  under  the  profundus  is  reached 


TENOSYNOVITIS  OF  FINGER  AND   ULNAR  BURSA     269 

that  one  finds  the  pus.  Again,  a  second  fallacious 
reason  for  stopping  the  incision  at  this  stage  may  be 
found.  There  may  be  a  subcutaneous  accumulation  of 
pus  on  the  flexor  surface  of  the  wrist,  in  all  probability 
of  lymphatic  origin;  this  having  been  opened,  the 
operator  feels  that  he  has  drained  a  pocket  in  direct 
communication  with  the  tendon  sheath  or  may  fear 
that  his  diagnosis  of  tendon-sheath  infection  has  been 
incorrect. 

Because  of  necrosis  of  tendons  or  superficial  involve- 
ment of  the  tendons  above  the  wrist,  it  may  be  deemed 
advisable  to  make  drainage  upon  the  flexor  surface. 
The  anterior  annular  ligament  may  or  may  not  be  cut 
as  is  indicated  in  the  given  case.  If  we  wish  to  open 
the  tendon  sheath  above  the  ligament  without  cutting 
it,  the  line  of  incision  lies  about  one-half  inch  to  the 
radial  side  of  the  ulnar  artery.  Generally,  however, 
the  swelling  is  such  that  the  pulsation  of  this  vessel 
cannot  be  felt.  It  is  then  necessary  to  proceed  by 
choosing  a  point  at  the  junction  of  the  middle  and  ulnar 
thirds  .of  the  flexor  surface  and  incising  carefully, 
layer  by  layer,  until  the  group  of  flexor  tendons  is 
reached.  These  can  be  identified  by  moving  the  fingers. 
The  dissection  is  now  carried  down  along  the  ulnar 
border  of  these  tendons  in  juxtaposition  to  them  and 
immediately  above  the  anterior  annular  ligament, 
since  the  sheath  lies  to  the  ulnar  side  and  posterior  to 
the  tendons.  If  infected,  it  should  be  freely  opened, 
since  the  swelling  due  to  edema  and  inflammatory 
infiltration  tends  to  close  a  small  opening.  If  the 
infection  is  now  seen  to  be  at  all  severe,  the  anterior 
annular  ligament  is  split  as  far  to  the  ulnar  side  as 
possible.  The  hook  of  the  unciform  interferes  some- 
what with  the  incision.  If  it  is  determined  when 
the  palmar  part  is  first  incised  that  the  anterior 
annular  ligament  shall  be  cut,  one  proceeds  differently. 


270     TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 

The  incision  is  continued  from  below  upward,  carrying 
the  incision  about  an  inch  up  on  the  forearm.  This 
latter  is  made  as  much  to  drain  the  subcutaneous 
area  above  the  wrist,  which  commonly  becomes  in- 
fected, as  to  open  the  sheath.  This  method  of  drainage 
of  the  upper  part  of  the  sheath  and  the  forearm  was 
used  exclusively  in  my  early  cases  before  I  began  to 
use  the  transverse  drainage  under  the  tendons,  and, 
while  fairly  satisfactory,  it  in  no  way  compares  with 
the  transverse  drainage  in  ordinary  cases.  Its  use 
should  be  restricted  to  exceptional  cases. 

Concerning  drainage  in  these  wounds,  it  has  been 
my  experience  that  when  incision  has  been  made  in 
this  manner  no  drainage  material  is  necessary  in  the 
majority  of  cases.  If  it  is  desired  and  there  is  no 
hemorrhage,  I  insert  strips  of  gutta-percha  tissue, 
while  if  there  is  hemorrhage  small  strips  of  gauze 
thoroughly  saturated  with  vaseline  are  packed  into 
the  wound. 

It  seems  especially  unsurgical  to  draw  rubber  tubes 
or  gauze  under  the  anterior  annular  ligament,  and  I 
never  use  them.  The  drainage  is  not  improved  and 
pressure  necrosis  is  favored.  Moreover,  where  drain- 
age at  the  wrist  is  unsatisfactory,  I  have  had  little 
cause  to  be  displeased  with  the  splitting  of  the  anterior 
annular  ligament.  No  case  has  been  seen  in  which  I 
felt  that  that  procedure  per  se  had  resulted  in  loss  of 
function,  and  I  have  frequently  seen  entire  restoration 
of  function  after  it  had  been  cut. 

TREATMENT  OF  EXTENSIONS  FROM  THE  LITTLE 
FINGER  AND  THE  ULNAR  BURSA. — The  treatment  of  the 
various  extensions  in  the  finger  proper  is  the  same  as 
that  outlined  while  discussing  the  index  finger.  When 
we  come  to  the  base  we  may  have  extension  either 
into  the  ulnar  bursa,  the  lumbrical  space,  or  both. 
In  the  more  acute  cases  the  former  alone  is  more 


TENOSYNOVITIS  OF  FINGER  AND   ULNAR  BURSA     271 

common,  while  in  the  more  chronic  type  it  is  often 
both.  Here  the  incision  opening  the  tendon  sheath 
can  be  made  to  drain  the  lumbrical  space. 

Extensions  into  the  middle  palmar  space  are  opened 
by  following  along  the  lumbrical  space  as  in  the  other 
fingers  if  the  ulnar  bursa  is  uninvolved.  If  this  latter 
is  invaded,  the  same  incision  which  opens  the  ulnar 
bursa  may  be  utilized  by  inserting  the  forceps  through 
the  synovial  wall  of  the  bursa  under  the  tendons  into 
this  space.  If  the  pus  has  extended  over  to  the  thenar 
space  it  should  be  drained  by  making  the  incision  upon 
the  dorsum  between  the  metacarpal  bones  of  the 
thumb  and  index  finger  and  opening  it  by  the  forceps, 
as  was  described  above  when  discussing  the  extensions 
from  the  index  finger. 

The  treatment  of  involvement  of  the  wrist-joint 
will  be  discussed  in  detail  in  Chapters  XXVII  and 
XXVIII,  dealing  with  chronic  processes  and  compli- 
cations. 

Beginning  invasion  of  the  forearm  has  already  been 
touched  upon.  Those  cases  presenting  marked  in- 
volvement of  the  forearm  are  best  treated  by  incisions 
as  follows  (Figs.  122  and  125): 

First,  incision  upon  either  side  just  above  the  wrist, 
allowing  drainage  of  the  subtendinous  space  under 
the  profundus  digitorum,  as  described  above.  These 
incisions  should  be  increased  to  two  or  three  inches 
in  length  if  the  accumulation  of  pus  is  large.  This 
is  especially  true  of  the  ulnar  side,  where  even  longer 
incisions  can  be  made  with  advantage.  If  the  pus  has 
involved  the  intermuscular  septa  higher  up,  the  incision 
should  be  made  about  half-way  up  the  forearm  upon 
the  ulnar  side,  either  just  above  the  level  of  the  ulnar 
bone  or  about  an  inch  farther  up  on  the  flexor  surface, 
the  desire  being  in  the  first  instance  to  go  between  the 
flexor  carpi  ulnaris  and  the  ulna.  Here  the  muscle 


272     TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 

must  be  separated  from  the  bone.  In  the  second  in- 
stance we  attempt  to  go  between  the  muscular  body 
of  the  flexor  carpi  ulnaris  and  the  inner  border  of  the 
flexor  sublimis  digitorum.  This  latter  incision  gives 
better  drainage,  but  there  is  some  danger  of  injuring 
the  ulnar  artery  either  primarily  or  secondarily.  The 
incision  between  the  ulna  and  the  flexor  carpi  ulnaris 
is  safer  and  is  sufficiently  satisfactory  to  give  good 
results  in  a  majority  of  cases.  This  one  incision  may 
be  extended  three  to  four  inches  and  generally  is 
all  that  is  necessary  in  these  cases.  The  incisions 
through  the  flexor  surface  upon  the  middle  or  radial 
side  should  be  condemned.  Particularly  in  those 
lying  upon  the  middle,  i.  e.,  going  through  the  flexor 
sublimis  digitorum,  the  inflammatory  swelling  of  the 
muscular  mass  acts  as  an  effective  barrier  to  free 
drainage.  I  have  yet  to  see  the  case  in  which  the  ulnar 
incision  supplemented  by  the  incisions  above  the 
wrist,  as  described,  failed  to  give  free  and  satisfactory 
drainage.  (For  a  complete  discussion  of  forearm  in- 
volvement and  treatment  see  Chapters  XXVI  and 
XXVII.) 

At  times  it  may  be  necessary  to  make  some  incisions 
through  the  skin  for  the  liberation  of  subcutaneous 
accumulations  of  pus,  probably  lymphatic  in  origin. 
The  most  common  site  for  this  is  immediately  above 
the  wrist  on  the  flexor  surface. 

Secondary  hemorrhage  is  nearly  always  from  the 
ulnar  artery.  It  will  generally  be  advisable  to  ligate 
this  after  verifying  the  fact  that  it  is  the  vessel  at 
fault,  since  repeated  hemorrhages  are  likely  to  occur 
if  tamponade  is  depended  upon,  and  the  patients  are 
generally  not  in  condition  to  withstand  many  hemor- 
rhages. (For  a  complete  discussion  of  this  subject  see 
Chapters  XXVI  and  XXVII.) 

When  the  radial  bursa  becomes  involved  secondarily 


INFLAMMATION  OF  TENDON  SHEATH  OF  THUMB    273 

to  the  ulnar  bursa,  it  should  be  treated  as  a  primary 
radial  bursa  infection,  which  we  will  discuss  below. 
Primary  dressing  and  after-treatment  are  discussed 
later. 

TREATMENT  OF  INFLAMMATION  OF  THE  TENDON  SHEATH  OF  THE  LONG 
FLEXOR  OF  THE  THUMB. 

Here  it  is  my  habit  to  dissect  down  to  the  tendon 
upon  the  flexor  surface  of  the  proximal  phalanx;  after 
entering  the  sheath,  the  incision  is  enlarged  along  the 
sac  through  the  thenar  eminence,  separating  the  mus- 
cular mass  (heads  of  the  flexor  brevis  pollicis).  It 
should  be  remembered  that  the  tendon  lies  nearer  the 
palm  than  one  would  be  inclined  to  think,  and  that  the 
mass  of  the  thenar  muscles  lies  to  the  radial  side  of 
the  incision.  This  is  only  carried  up  to  within  a  thumb's 
breadth  of  the  lower  border  of  the  anterior  annular  liga- 
ment. I  limit  the  incision  at  this  point,  since  with  the 
assistance  of  Professor  P.  T.  Burns  and  Dr.  A.  T.  Horn, 
at  the  Anatomical  Laboratory  of  the  Northwestern 
University  Medical  School,  I  made  a  careful  examina- 
tion of  85  cadaver  hands,  with  the  result  that  it  was 
shown  that  the  motor  nerve  to  the  thenar  muscles 
passes  across  the  sheath  between  this  point  and  the 
lower  edge  of  the  anterior  annular  ligament,  and  in 
my  opinion  loss  of  the  flexor  longus  pollicis  tendon  is 
to  be  preferred  to  destroying  this  nerve  and  thus  bring- 
ing about  a  loss  of  the  muscles  which  it  supplies. 
Drainage  of  the  upper  end  of  the  radial  bursa  is  best 
carried  out  by  the  methods  described  above  when 
discussing  drainage  of  the  upper  end  of  the  ulnar 
bursa.  Incisions  are  made  laterally  at  the  flexor  sur- 
face of  the  ulna  and  radius  and  through-and-through 
drainage  secured  under  the  flexor  profundus  tendons. 
At  times  incision  upon  the  radial  side  alone  will  be 
sufficient  if  the  sheath  has  not  already  ruptured.  If 

18 


it  has  not  ruptured,  two  fingers  are  thrust  into  the 
radial  incision  under  the  tendons  and  a  grooved  director 
or  forceps  is  pushed  up  from  the  palmar  incision  along 
the  sheath.  The  end  of  the  forceps  is  easily  felt  in  the 
forearm  under  the  tendons.  The  sheath  is  opened  and 
gauze  saturated  with  vaseline  or  gutta-percha  strips 
inserted  into  the  wound  for  drainage.  (For  a  further 
study  of  the  basis  upon  which  this  method  is  advised 
see  Chapters  XXVI  and  XXVII.) 

At  times  an  accumulation  of  pus  will  be  found  on 
the  forearm  subcutaneously  just  above  the  wrist  upon 
the  radial  side.  When  this  is  opened  the  surgeon  may 
be  of  the  opinion  that  the  sheath  has  ruptured  and  is 
thus  draining  anteriorly;  hence,  he  will  desist  from 
drainage  of  the  deeper  tissue.  Such  an  accumulation 
is  of  lymphatic  origin  and  has  no  connection  with  the 
sheath,  so  that  the  lateral  incisions  described  above 
should  always  be  made  in  addition  to  this  skin  incision 
in  front. 

At  times,  owing  to  necrosis  of  tendons  or  extensive 
suppuration  among  them,  it  may  be  advisable  to  drain 
the  sheath  from  the  front,  in  which  case  an  incision 
is  made  going  a  quarter  of  an  inch  to  the  radial  side 
of  the  median  line  of  the  flexor  surface  of  the  forearm. 
The  dissection  is  carried  down  to  the  radial  side  of  the 
flexor  sublimis  tendons,  avoiding  the  median  nerve 
which  lies  in  the  floor  and  to  the  ulnar  side.  The  ten- 
don sheath  has  generally  ruptured  by  this  time,  or  can 
be  identified  by  a  grooved  director  or  fine  probe  passed 
from  the  opened  sheath  below.  It  is  entirely  safe  to 
cut  the  upper  part  of  the  anterior  annular  ligament 
(Fig.  88). 

In  almost  every  case,  however,  I  feel  that  this  anterior 
incision  should  be  limited  to  opening  the  subcutaneous 
accumulation  if  there  be  any,  and  the  tendon  sheath 
should  be  opened  by  the  lateral  incisions  described 


INFLAMMATION  OF  TENDON  SHEATH  OF  THUMB    275 

above  for  entering  the  space  between  the  flexor  pro- 
fundus  tendons  and  the  pronator  quadratus.  Good- 
sized  incisions  should  be  made,  so  that  drainage  may 
be  free. 

If  many  cases  where  the  infection  has  been  severe 
or  the  tendon  impaired  primary  removal  of  the  tendon 
should  be  favored.  This  is  particularly  liable  to  die 
and  remain  for  many  weeks,,  causing  the  infection  to 
persist  and  jeopardize  other  structures,  so  that  if  the 
tendon  is  at  all  destroyed  or  the  infection  shows  a 
slow  recovery  it  should  be  removed  at  once.  I 
am  also  especially  inclined  to  do  this  if  the  ulnar 
bursa  has  so  far  escaped  involvement,  since  the  preser- 
vation of  this  is  particularly  to  be  sought. 

The  principles  of  treatment  of  involvement  of  the 
thenar  space  and  the  ulnar  bursa  have  already  been 
discussed.  In  relation  to  secondary  ulnar  sheath  in- 
fection, it  may  be  noted  that  there  is  doubt  frequently 
as  to  the  diagnosis  in  these  cases.  In  such  cases  it  is 
advisable  to  dissect  down  carefully  upon  the  sheath  in 
the  lower  third  of  the  palm  just  to  the  radial  side  of 
the  hypothenar  space.  After  the  palmar  fascia  is  cut 
a  pad  of  edematous  fat  will  be  seen  to  bulge  into  the 
wound  as  if  there  were  great  tension  in  the  subaponeu- 
rotic  palmar  space.  This  fat  having  been  dissected 
away,  the  tense  bursa  will  be  seen  to  bulge  into  the 
field.  This  is  opened  and  the  operation  proceeds  as 
described  above  while  discussing  the  technique  of 
treatment  of  the  ulnar  bursa.  There  is  always  a  grave 
decision  to  make  as  to  whether  or  not  the  sheath  of 
the  little  finger  tendon  has  become  involved,  and 
therefore  should  also  be  opened.  Involvement  of  the 
carpal  joints  is  discussed  in  Chapter  XXVI. 

When  the  forearm  becomes  involved,  the  treatment 
is  the  same  as  when  the  involvement  has  originated 
from  the  ulnar  bursa,  since  the  foci  of  extension  are 
the  same. 


276     TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 

The  case  of  Mr.  W.  is  reported,  since  it  is  probably 
the  most  virulent  case  of  tenosynovitis  beginning  in 
the  thumb  and  extending  over  by  way  of  the  tendon 
sheath  of  the  flexor  longus  pollicis  to  the  ulnar  bursa 
that  I  have  had  an  opportunity  to  observe.  The 
infection  was  virulent  and  the  toxic  symptoms  so 
severe  as  to  threaten  the  patient's  life.  The  result 
was  very  satisfactory  considering  the  fact  that  the 
case  did  not  come  under  observation  until  after  the 
sheath  had  been  involved  for  at  least  thirty-six  hours. 
In  this  case  there  was  a  complete  restoration  of  func- 
tion of  the  entire  hand  and  fingers,  with  the  possible 
exception  of  slight  loss  of  flexion  of  the  distal  phalanx 
of  the  little  finger.  This  result  is  a  marked  contrast 
to  those  cases  of  similar  nature  which  I  have  seen 
several  days  after  the  sheath  had  become  involved, 
when  such  destruction  of  the  tendons  and  their  cover- 
ings had  taken  place  as  to  preclude  the  possibility  of 
a  favorable  outcome  no  matter  what  the  surgical 
procedure  might  be.  The  history  of  the  case  is  prac- 
tically identical  with  one  seen  two  months  previously, 
which  had  remained  eight  days  without  opening.  The 
general  health  and  resistance  of  the  individuals  were 
much  the  same.  The  outcome  in  the  first  case  which 
had  been  treated  conservatively  was  most  disastrous, 
the  patient  barely  escaping  with  his  life  and  ending 
with  a  functionless  hand.  After  observing  these  two 
cases,  so  close  together  and  with  such  similar  condi- 
tions, I  cannot  but  feel  that  under  these  conditions 
conservatism  is  most  inadvisable,  and  that  the  earliest 
possible  opening  of  the  sheath  is  indicated. 

CASE  XIII.— Mr.  W.,  referred  by  Dr.  Colleran,  Post- 
Graduate  Hospital,  July,  1908  (Fig.  92). 

Patient  gave  a  history  of  having  run  a  splinter  of  wood 
into  the  distal  phalanx  of  the  thumb  seven  days  previous 
to  coming  to  the  clinic.  This  had  been  removed  with  a 


INFLAMMATION  OF  TENDON  SHEATH  OF  THUMB    277 

penknife,  and  later,  at  the  end  of  five  days,  another 
splinter  had  been  removed.  Three  days  before,  he  began 
to  complain  of  pain  over  the  course  of  the  thumb  and 
radial  side  of  the  hand.  The  whole  hand  now  became 
tender  and  swollen. 

FIG.  92 


Photograph  showing  the  incision  in  the  case  of  Mr.  W.,  splitting  of  the 
ulnar  bursa  and  radial  bursa  and  incisions  above  the  wrist.  Accompanying 
photographs  show  result  two  and  one-half  months  after  treatment.  (See 
Case  XIII.) 

On  examination,  temperature  was  101°;  pulse,  96. 
The  whole  hand  was  found  to  be  swollen  on  both  the 
flexor  and  dorsal  surfaces,  as  was  also  the  forearm.  Con- 
cavity of  the  palm  was  still  present.  Tenderness  was 
most  marked  at  the  wrist-joint  and  slightly  above  on  both 
the  radial  and  ulnar  sides.  There  was  tenderness  also 
along  the  course  of  the  ulnar  bursa  in  the  palm  of  the  hand 
and  over  the  tendon  sheath  of  the  little  finger.  There  was 
only  slight  tenderness  in  the  palm  of  the  hand.  Tenderness 
is  also  found  over  the  course  of  the  flexor  longus  pollicis. 
There  is  no  tenderness  over  the  index,  middle,  or  ring 
fingers,  and  none  on  the  dorsum.  On  extension  of  the 
fingers,  extension  of  the  little  finger  and  thumb  caused 


278     TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 

marked  pain,  the  ring  finger  slight  pain,  and  the  middle 
and  index  fingers  very  little  pain. 

Diagnosis  of  tenosynovitis  of  the  flexor  longus  pollicis, 
the  intermediary  sheaths  at  the  wrist,  and  the  ulnar  bursa 
was  made. 

Operation. — General  anesthesia;  Esmarch's  bandage 
applied.  Incision  was  made  through  the  skin  and  sub- 
cutaneous tissue  over  the  ulnar  bursa  in  the  lower  third 
of  the  palm.  After  cutting  through  the  palmar  fascia  the 
fat  bulged  into  the  wound.  This  was  split  and  the  bulging 
sheath  was  seen  beneath.  This  was  opened  and  pus  found. 
The  sheath  was  then  opened  throughout  its  length  from 
the  base  of  the  middle  finger  up  to  and  through  the  anterior 
annular  ligament  (Fig.  92).  Pus  was  found  throughout. 
An  incision  was  then  made  in  the  forearm  on  either  side 
at  the  level  of  the  flexor  surfaces  of  the  ulna  and  radius, 
one  inch  above  the  anterior  annular  ligament;  an  artery 
forceps  was  passed  underneath  the  tendons  of  the  flexor 
profundus  digitorum.  A  slight  amount  of  pus  was  found 
here.  An  artery  forceps  now  opened  the  sheath  of  the 
ulnar  bursa  at  its  upper  end,  passing  into  the  space  under- 
neath the  flexor  tendons,  and  a  finger  enlarged  the  opening. 

An  incision  was  made  over  the  proximal  end  of  the 
proximal  phalanx  of  the  thumb  into  the  sheath  of  the 
flexor  longus  pollicis.  A  small  amount  of  slightly  turbid 
fluid  was  present  that  was  not  clearly  pus.  The  opening 
was  extended,  however,  to  the  distal  end,  where  consider- 
able pus  was  evacuated.  The  incision  was  then  extended 
upward  along  the  sheath  to  within  a  thumb's  breadth  of 
the  lower  border  of  the  anterior  annular  ligment.  Free 
pus  was  found  here  also.  An  artery  forceps  was  then 
passed  along  the  sheath  up  into  the  forearm  underneath 
the  flexor  profundus  tendons,  communicating  with  the 
opening  previously  made. 

After  washing  the  sheath  out  thoroughly  with  normal 
salt  solution,  strips  of  gauze  saturated  with  vaseline  were 
laid  between  the  cut  edges  of  the  skin  and  also  drawn 
underneath  the  flexor  profundus.  Hot  boric  dressings 
were  applied. 

Subsequent  Course. — Pain  was  immediately  relieved, 
temperature  fell  to  99°,  around  which  it  remained,  at  no 
time  going  higher  than  100°,  and  the  patient  made  a 


INFLAMMATION  OF  TENDON  SHEATH  OF  THUMB    279 

gradual  and  satisfactory  recovery.  At  the  end  of  twenty- 
four  hours  the  hot  boric  dressings  were  changed  for  dry 
dressings,  the  inner  layer  of  which  was  saturated  with 
vaseline.  The  strips  of  gauze  between  the  edges  of  the 
wound  were  removed,  the  hand  was  dressed  in  dorsal 
extension  on  a  right-angled  dorsal  splint  (Fig.  93). 

FIG.  93 


Photograph  showing  the  dorsal  right-angled  splint  used  after  splitting  the 
annular  ligament  in  infection  of  the  ulnar  bursa.  In  the  photograph  the  hand 
has  been  loosened  from  the  dressing  so  as  to  show  the  right  angled  splint. 

Subsequent  Treatment. — Each  day  the  hand  was  dressed, 
each  of  the  articulations  was  moved,  including  the  finger- 


280     TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 

joints  and  wrist,  and  the  hand  dressed  in  dorsal  extension. 
On  the  fifteenth  day  it  was  deemed  advisable  to  open 
the  tendon  sheath  of  the  little  finger,  which  had  not 
been  opened  at  the  time  of  operation.  A  small  amount  of 
pus  was  evacuated,  and  I  believe  it  would  have  been 
advisable  to  have  opened  this  sheath  at  the  time  of  the 
primary  operation.  The  incisions  over  the  flexor  longus 
pollicis  were  completely  healed  at  the  end  of  three  and 
one-half  weeks.  Those  above  the  wrist  closed  at  the 
end  of  five  days.  That  over  the  tendons  of  the  ulnar  bursa 
was  completely  closed  at  the  end  of  four  and  one-half 
weeks.  At  that  time  the  patient  could  move  slightly  all 
the  fingers  of  the  hand,  and  flex  voluntarily,  with  the 
exception  of  the  little  finger,  every  joint,  including  the 
wrist.  He  was  urged  to  use  his  hand  repeatedly  and  to 
return  for  passive  motions.  In  this  respect  he  was  some- 
what dilatory.  At  the  beginning  of  the  sixth  week  his 
hand  was  treated  daily  in  the  Klapp  apparatus  for  break- 
ing up  adhesions,  and  at  the  end  of  the  ninth  week  he 
began  to  work  with  his  hand,  and  at  the  end  of  the  twelfth 
week  he  had  practically  complete  function  of  all  joints 
and  fingers,  with  the  exception  of  the  little  finger,  where 
there  was  only  25  per  cent,  of  function.  This  will  improve, 
but  will  never  be  perfect  (Fig.  92). 

The  following  case  of  acute  streptococcic  infection 
of  the  flexor  longus  pollicis  is  reported  in  some  detail, 
since  it  is  one  in  which  the  patient  narrowly  escaped 
with  her  life,  and  shows  the  course  in  these  cases;  and 
because  the  sheath  ruptured  permitting  involvement 
of  the  subprofundus  space  without  involvement  of  the 
ulnar  bursa. 

The  complete  restoration  of  the  tendon  function  in 
this  case  is  most  encouraging.  I  believe  that  with  an 
early  incision,  carefully  followed  by  conservative  treat- 
ment, we  can  hope  for  much  better  results  in  the  future 
than  in  the  past. 

CASE  XIV. — Dr.  S.,  seen  in  consultation  with  Dr. 
Besley,  gave  the  following  history  which  is  abbreviated 
from  the  history  sheets  of  the  hospital. 


INFLAMMATION  OF  TENDON  SHEATH  OF  THUMB    281 

January  23.  Pulse,  100;  temperature,  101.8  °;  respira- 
tions, 26.  Hot  dressings  applied  to  right  arm;  under 
nitrous  oxide  anesthesia,  Dr.  M.  L.  Harris  incised  the 
flexor  surface  of  the  thumb.  Condition  good. 

January  24.  Pulse,  80;  temperature,  98.6°;  respira- 
tions, 20.  Slept  fairly  well.  Condition  seems  very  much 
improved. 

January  26.    Leukocytosis,  11,000. 

January  27.  Pulse,  64;  temperature,  98°;  respirations, 
20.  Entire  thumb  swollen  and  pus  oozes  from  incisions. 
Thumb  again  incised  by  Dr.  Charles  Davison;  drainage 
inserted.  Normal  salt  enemas  given  every  four  hours;  hot 
boric  acid  solution  to  part;  5  P.M.,  pulse,  80;  temperature, 
101  °;  respirations,  20. 

January  29,  4  A.M.  Pulse,  108;  temperature,  102.8°; 
respirations,  26;  8  A.M.,  pulse,  80;  temperature,  103.4°; 
respirations,  22;  leukocytosis,  21,000.  Thumb  irrigated 
with  hot  boric  and  peroxide;  dry  dressings  applied;  9  P.M., 
temperature,  102.2°;  palm  of  hand  greatly  swollen  and 
angry  red  extending  into  wrist.  Vomited  small  amount 
of  fluid. 

January  30,  9  A.M.  Temperature,  101.6°;  nauseated 
and  vomited  greenish  fluid;  face  flushed;  slept  very 
little. 

January  31,  9  A.M.  Temperature,  101.4°;  pulse,  96; 
respirations,  20.  Swelling  on  hand  increasing  and  extend- 
ing; under  gas-ether  anesthesia  Dr.  F.  A.  Besley  made 
an  incision  into  the  radial  bursa,  liberating  yellowish  pus. 
Rubber  drain  inserted,  allowing  free  drainage  between 
first  and  second  metacarpals.  Small  incision  made  above 
wrist,  but  no  pus  found  in  arm,  although  there  was  con- 
siderable redness  and  swelling. 

February  I.  Pulse,  84;  temperature,  102°;  respira- 
tions, 20.  Slept  some  since  10  P.M.  Pain  in  hand.  Hot 
dressings.  Smears  from  pus  show  short  chains  of  strepto- 
cocci. 

February  2.  Temperature,  101.6°;  leukocytosis,  24,000. 
Feels  rather  drowsy.  Does  not  have  much  pain.  Slept 
at  intervals. 

February  3.  Pulse,  84;  temperature,  100.2°;  respira- 
tions, 20.  Cultures  on  agar  and  in  bouillon  show  only 
streptococci;  leukocytosis,  32,000.  Under  gas  anesthesia 


282     TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 

incisions  enlarged  and  opened  wide  by  forceps  by  Drs. 
Besley  and  Kanavel. 

February  4,  I  A.M.  Pulse,  80;  temperature,  102°; 
9  P.  M.,  temperature,  101°.  Slept  most  of  forenoon. 

February  5,  10  A.M.  Temperature,  102°.  Hand 
dressed.  Swelling,  hyperemia,  and  tenderness  along  flexor 
surface  of  arm,  radial  side.  Pus  oozes  from  wounds.  Good 
night's  rest;  4  P.M.,  pulse,  112;  temperature,  103°;  respir- 
ations, 24.  Another  incision  made  in  forearm  by  Dr. 
Besley.  The  incision  was  made  on  radial  surface  of  arm, 
and  liberated  a  large  quantity  of  yellow  pus.  Gauze  pack- 
ing inserted.  Gas  anesthesia.  7.30  P.M.,  gauze  packing 
removed.  Patient  rather  restless. 

February  6.  Pulse,  92;  temperature,  102°;  respira- 
tions, 20. 

February  7.  Pulse,  90;  temperature,  99.4°;  respirations, 
20.  Patient  very  comfortable.  Small  superficial  pocket 
of  pus  on  anterior  surface  of  wrist  opened  by  Dr.  Besley. 

February  8.     Pulse,  80;  temperature,  98°;  respirations, 

20. 

FIG.  94 


Photograph  showing  the  function  present  in  Case  XIV;   infection  of  the 
radial  bursa,  three  months  after  treatment. 

From  this  time  on  the  temperature  remained  normal. 
Patient  gradually  improved,  and  was  discharged  February 
24.  The  wound  in  the  thenar  space  closed  about  two 
weeks  later. 


SYNOVIAL  SHEATHS  ON  THE  DORSUM 


283 


Subsequent  History. — At  the  end  of  five  months  the  case 
presents  a  complete  restoration  of  function  of  the  muscles 
of  the  thumb  and  the  tendon  of  the  flexor  longus  pollicis, 
and  the  tendons  of  the  hand  upon  flexion  (Fig.  94). 


SYNOVIAL  SHEATHS  ON  THE  DORSUM. 


When   the  synovial  sheaths  upon   the  dorsum  are 
infected,  a  simple  splitting  of  the  sheath  throughout 

FIG.  95 


Acute  suppurative  dorsal  tenosynovitis.  Note  the  area  of  surrounding 
edema.  The  tendon  sheath  is  only  about  one-half  the  length  of  the  tume- 
faction. 

its  length  apparently  gives  the  best  results.  I  have  had 
only  four  of  these  cases  due  to  acute  infection,  and  they 
all  recovered  with  good  function  after  a  short  time, 


284    TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 

with  the  exception  of  the  case  in  which  this  involve- 
ment was  associated  with  a  palmar  infection,  when 
a  fatal  issue  followed  (Case  XXII,  Fig.  95). 


AFTER-TREATMENT. 

DRAINAGE. — The  use  of  drainage  has  been  discussed 
by  every  surgeon,  and  the  principles  underlying  it  here 
are  the  same  as  elsewhere.  Those  who  after  much 
experience  and  thought  have  decided  upon  its  use  will 
probably  use  it  here.  My  own  results  have  led  me 
to  abandon  it  almost  extirely.  I  never  use  a  rubber 
tube,  owing  to  my  fear  of  pressure  necrosis.  Gauze,  if 
left  in  many  hours,  begins  to  act  as  a  plug.  Unless 
there  is  bleeding,  it  is  not  used.  If,  however,  one  fears 
that  the  skin  will  close  down  at  once  and  prevent  the 
escape  of  pus,  gauze  saturated  with  vaseline  is  inserted. 
I  have  found  this  to  give  good  drainage  and  not  to 
act  so  much  as  a  plug,  yet  giving  tampon  pressure 
in  cases  of  oozing.  Strips  may  be  inserted  from  the 
sides  above  the  wrist  under  the  flexor  profundus,  and 
also  above  into  the  ulnar  incision  on  the  forearm.  I 
have  also  used  gutta-percha  strips  with  satisfaction. 
In  my  earlier  cases  drainage  tubes  were  inserted 
through  from  the  palm  to  the  dorsum,  after  the  older 
methods  of  palmar  drainage,  but  since  introducing 
palmar  drainage  along  the  lumbrical  spaces  this  pro- 
cedure has  been  abandoned  entirely. 

In  the  virulent  cases,  every  attempt  is  made  not  to 
manipulate  the  arm  and  hand  any  more  than  is  neces- 
sary, so  as  to  protect  the  patient  against  absorption 
of  toxins  as  much  as  possible.  The  application  of  the 
Bier  method  of  constriction  of  the  arm  to  prevent  the 
rapid  absorption  of  bacteria  and  toxins  during  and 
immediately  after  incision  has  already  been  touched 
upon.  During  the  after-treatment  the  same  pre- 


AFTER-TREATMENT  285 

cautions  are  taken  so  long  as  the  process  is  acute.  The 
area  is  kept  immobilized  and  slightly  elevated.  This 
latter  is  done  to  secure  comfort  as  much  as  to  aid  in 
recovery.  The  von  Volkmann  treatment,  i.  e.,  vertical 
elevation  of  the  hand,  has  not  seemed  to  me  to  be 
of  great  therapeutic  value,  although  apparently  it  is 
a  valuable  procedure  in  that  it  prevents  excessive 
edema  in  the  later  stages. 

For  the  first  few  days  after  incision  it  would  appear 
that  hot,  moist  dressings  are  of  value  to  relieve  the 
pain  and  promote  walling  off  of  the  infection.  After 
this  stage  they  should  be  abandoned  in  favor  of  dry 
dressings,  since  they  seem  to  produce  excessive  granu- 
lation. In  several  cases  I  have  been  able  to  apply  dry 
dressings  at  the  end  of  twenty-four  hours.  The  hot, 
moist  dressings  are  generally  made  from  a  saturated 
solution  of  boric  acid.  However,  it  is  probable  that 
the  moist  heat  is  the  essential  factor.  Strong  anti- 
septic solutions,  such  as  bichloride  and  carbolic  acid, 
are  never  used.  The  inner  layer  of  the  dry  gauze  may 
be  saturated  with  vaseline  to  prevent  it  adhering  to  the 
wound. 

The  hand  is  dressed  from  once  to  twice  daily.  If 
gauze  has  been  inserted  and  has  adhered  to  the  wound, 
there  is  less  shock  produced  by  anesthetizing  the  patient 
with  a  small  amount  of  nitrous  oxide  than  is  given  by 
the  pain  incident  to  withdrawal  without  such  an  aid. 

The  hand  is  dressed  with  the  fingers  in  extension 
upon  a  dorsal  splint.  This  is  done  to  prevent  prolapse 
of  the  tendons.  In  the  fingers  this  procedure  is  of 
special  importance,  not  only  to  avoid  the  prolapse  of 
the  tendons,  but  also  to  prevent  all  of  the  fingers 
tending  to  become  flexed  in  one  position.  In  the  first 
few  dressings  the  hand  may  be  flexed  and  normal  salt 
irrigation  used  to  wash  out  about  the  tendons. 

The  prolapse  of  the  tendons  at  the  wrist  is  prevented 


286    TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 

by  dressing  the  hand  with  the  wrist  sharply  bent 
backward.  I  ordinarily  mould  a  plaster  of  Paris 
splint  to  fit  the  back  of  the  forearm  up  to  the  wrist; 
here  the  plaster  splint  is  bent  back  at  a  right  angle. 
The  hardened  splint  is  applied  to  the  forearm  and 
held  in  place  by  a  bandage.  A  second  bandage  now 
attempts  to  bring  the  hand  back  to  the  horizontal 
prolongation.  At  times  I  have  used  light  elastic 
pressure.  The  tension  and  position  are  varied  from  day 
to  day  after  danger  of  prolapse  has  ended,  so  as  to 
prevent  ankylosis  of  the  tendons  and  joint  in  one 
position.  The  primary  splint  is  applied  immediately 
after  the  operation  (Fig.  93). 

The  prevention  of  adhesions  in  the  joints,  preserva- 
tion of  the  vitality  of  the  muscles,  and  the  use  of  the 
tendons  is  most  important,  and  at  times  the  results 
are  discouraging.  Unfortunately  the  surgeon  so  often 
sees  these  cases  after  primary  incisions  have  been  made 
and  the  case  treated  for  several  days.  In  the  severe 
fulminating  types  this  has  permitted  such  destruction 
of  the  tendons  and  synovial  coverings  as  to  make  any 
after-treatment  of  little  avail.  It  seems  to  me  advisable 
to  begin  passive  and  active  movements  within  a  few 
days  after  primary  incisions;  in  other  words,  as  soon 
as  the  danger  of  systemic  infection  is  over.  I  do  not 
believe  that  the  local  condition  is  made  materially 
worse,  and  we  do  aid  in  the  prevention  of  firm  adhesions. 
It  is  better  to  do  this  in  baths  of  very  hot  water,  which 
relieves  the  pain  to  some  extent  and  helps  to  cleanse 
the  discharging  wound.  The  patient's  hand  and  fore- 
arm being  immersed  in  hot  sterile  water,  the  surgeon 
with  glove-covered  hands  gently  flexes  and  extends 
each  finger,  as  well  as  the  hand  at  the  wrist,  several 
times.  Violent  movements  are  not  indulged  in.  The 
bath  is  not  kept  up  any  length  of  time,  since  we 
wish  to  prevent  rather  than  to  favor  the  development 


AFTER-TREA  TMENT 


287 


of  granulation  tissue  at  this  stage.  The  patient  is 
encouraged  to  make  active  movements  himself.  If  a 
dry,  hot  chamber  is  at  hand,  this  may  be  used  to 
advantage.  I  cannot  emphasize  too  strongly  the  impor- 
tance of  this  early,  gentle,  and  intelligent  manipulation. 
I  do  not  refer  to  massage,  but  to  the  intelligent  use 
of  the  various  joints,  muscles,  and  tendons. 

FIG.  96 


Showing  the  Bier  apparatus  for  production  of  mobility  in  stiffened 
tendons  and  joints. 

Bier  (Fig.  96)  and  others  (Fig.  97)  have  used  mechani- 
cal appliances  to  produce  the  same  effect.  The  force 
may  be  exerted  by  exhausting  the  air  in  a  chamber 
in  which  the  hand  has  been  placed,  the  hand  or  the 


288     TREATMENT  OF  SUPPURATIVE  TENOSYNOVITIS 

individual  fingers  being  applied  to  the  fixed  end  so 
that  when  the  air  is  exhausted  the  joints  are  flexed 
or  extended.  He  attributes  some  of  his  good  results 
to  the  therapeutic  effect  of  exhausting  the  air  and 
producing  a  hyperemia.  The  apparatus  also  has  the 
advantage  that  the  patient  will  be  more  persistent 

FIG.  97 


Showing  the  Klapp  apparatus  for  producing  mobility  in  stiffened  wrist-ioint. 

and  regular  in  the  application  of  the  treatment  than 
he  will  be  if  he  depends  on  treatment  by  the  surgeon 
alone.  The  results  of  treatment  may  be  materially 
bettered  by  such  an  apparatus,  as  I  have  had  oppor- 
tunity to  verify  in  my  late  cases.  The  surgeon  must 
not  expect  that  it  will  cure  old,  contracted  cases  or 
those  with  great  destruction  of  tissue. 


CHAPTER   XVII. 

THE  TREATMENT  OF  FASCIAL-SPACE 
ABSCESSES. 

WE  shall  here  consider  the  treatment  of  fascial 
space  abscesses  uncomplicated  by  tenosynovitis,  or  in 
case  of  complications  presenting  only  those  of  minor 
importance,  so  that  the  fascial-space  abscess  is  still 
the  predominant  picture. 

The  treatment  naturally  divides  itself  into  prophyl- 
actic and  active.  In  the  first  instance  all  wounds 
should  be  given  aseptic  care,  and  any  localized  infec- 
tion should  be  attended  to,  thorough  drainage  being 
instituted  before  the  infection  has  a  chance  to  spread. 
In  those  cases  in  which  we  are  waiting  to  decide 
whether  or  not  a  localized  abscess  is  present,  immobili- 
zation and  the  local  use  of  the  well-known  hot,  moist 
dressing  is  probably  more  efficient  than  any  other 
application.  The  usual  general  tonic  and  excretory 
procedures  should  be  instituted. 

Should  the  diagnosis  of  a  localized  accumulation  of 
pus  in  any  of  the  various  tissues  be  made,  our  first 
question  is,  What  is  the  best  site  for  incision?  for  we 
need  not  discuss  the  fact  that  such  a  condition 
as  that  demands  early  and  efficient  drainage.  Should 
the  subcutaneous  tissue  of  the  dorsum  or  the  areas 
under  the  epidermis  or  dermis  of  the  palm  be  involved, 
or  minor  infections  of  the  thenar  and  hypothenar  areas 
be  present,  a  wide  opening  by  simple  incision  is  gen- 
erally sufficient.  Should  the  middle  palmar,  thenar, 
lumbrical,  or  subaponeurotic  spaces  be  involved, 
however,  some  special  consideration  is  necessary. 
19 


290     TREATMENT  OF  FASCIAL-SPACE  ABSCESSES 
THE  MIDDLE  PALMAR  SPACE. 

TECHNIQUE  OF  TREATMENT. — It  is  probably  better 
to  err  upon  the  side  of  radicalism,  than  conservatism, 
when  confronted  with  a  possible  middle  palmar-space 
abscess,  owing  to  the  liability  of  complications  in  the 
ulnar  synovial  sheath,  the  bones,  and  the  joints,  if 
the  abscess  is  neglected. 

Any  method  of  opening  the  space  exposes  certain 
tissues  to  injury,  and  it  is  a  question  of  choosing  the 
least  dangerous  route.  It  cannot  be  opened  upon  the 
ulnar  side,  owing  to  the  fear  of  infecting  the  ulnar 
bursal  sheath;  a  flap  of  the  palmar  fascia  should  not 
be  dissected  up  from  below,  as  has  been  suggested, 
making  a  sort  of  trap-door,  as  it  were,  since  the  in- 
fection lies  below  the  tendons,  and  to  make  such  an 
opening  and  then  drain  anteriorly  between  the  tendons 
would  result  in  unnecessary  adhesions. 

The  least  injury  and  the  most  efficient  drainage  of 
the  middle  palmar  space  can  be  secured  by  an  incision 
along  one  of  the  three  lumbrical  canals  leading  into 
this  space,  i.  e.,  the  little  finger,  ring  finger,  or  the 
middle  finger  canals  (Fig.  98).  That  canal  will  be 
chosen  which  is  already  markedly  infected,  either  be- 
cause it  has  been  the  atrium  of  the  infection  or  because 
it  has  been  secondarily  involved.  If  the  surgeon  has 
any  choice  in  the  matter,  that  between  the  ring  and 
middle  finger  gives  the  most  satisfactory  drainage.  An 
incision  is  made  into  the  canal  and  carried  one-half 
inch  above  its  end  up  into  the  palmar  space,  i.  e., 
one-half  inch  proximal  to  a  line  joining  the  proximal 
end  of  the  distal  flexion  crease  with  the  distal  end 
of  the  middle  flexion  crease,  or,  grossly  speaking,  a 
thumb's  breadth  and  a  half  up  into  the  palm.  This 
brings  the  incision  between  the  tendons.  An  artery 
forceps  is  thrust  under  the  group  of  palmar  tendons 


THE  MIDDLE  PALMAR  SPACE 


291 


and  the  blades  opened,  satisfactory  drainage  ensuing. 
A  small  strip  of  gutta-percha  or  gauze  saturated  with 
vaseline  will  keep  the  opening  from  closing  for  a  day, 
after  which  time  it  will  not  be  needed.  I  think  that  I 


FIG.  98 


Showing  incisions  for  opening  the  lumbrical  space  and  for  opening  the 
lumbrical  space  in  conjunction  with  the  middle  palmar  space. 

am  indebted  to  Dr.  F.  A.  Besley  for  the  suggestion  as 
to  this  method  of  incision.  It  is  remarkable  how 
rapidly  cases  will  recover  under  this  treatment. 

Herewith  is  reported  the  first  case  in  which  I  used 
this  method.  I  have  used  it  many  times  since  with 
absolute  satisfaction. 


292     TREATMENT  OF  F ASCI AL-SP ACE  ABSCESSES 

CASE  XV. — Infection  base  of  palm  spreading  along 
lumbrical  canal  into  palm;  incision  along  canal.  Recovery 
with  perfect  function. 

M.  R.,  treated  at  the  Post-Graduate  Hospital,  July, 
1906.  Service  of  Prof.  F.  A.  Besley.  Five  days  before 
entrance  patient  developed  an  infection  from  the  crack 
of  a  callus  at  the  base  of  the  palm  of  the  right  hand  between 
the  ring  and  little  fingers.  An  abscess  had  formed  in  the 
fascial  space  at  the  base  of  these  fingers  and  extended  along 
the  lumbrical  canal.  Upon  investigation  it  was  found  to 
have  involved  the  middle  palmar  space.  This  was  diag- 
nosticated by  the  tenderness  localized  over  the  lumbrical 
canal,  and  the  bulging  of  the  palm  associated  with  local- 
ized tenderness.  The  incision  was  made  at  the  original 

FIG.  99 


Photograph  of  incision  in  a  case  of  infection  in  the  middle  palmar  space 
originating  in  web  at  end  of  lumbrical  canal.  Recovery  with  complete  func- 
tion in  ten  days.  (See  Case  XV.) 

site  of  the  infection,  passing  from  the  palm  through  the 
fascial  tissue  to  the  dorsum  between  the  proximal  phalanges 
of  the  fingers.  A  grooved  director  was  then  inserted  along 
the  lumbrical  canal,  which  was  opened  throughout  its 
extent,  the  incision  being  carried  up  to  the  middle  flexion 
crease  of  the  palm ;  in  other  words,  one-half  inch  above  the 
lumbrical  canal.  Forceps  were  now  inserted  underneath 
the  tendons,  opening  the  palmar  space  widely;  about  one 
ounce  of  pus  escaped ;  no  drain  was  inserted ;  hot  boric 
dressings  applied. 

Course. — At  the  end  of  ten  days  all  discharge  of  pus  had 
ceased  and  wound  had  healed.  At  the  end  of  three  weeks 
complete  function  was  present  in  all  the  fingers  and  hand 
(Fig.  99). 


TREATMENT  OF  PALMAR  AND  THENAR  SPACES    293 


THE  TREATMENT  OF  COMBINED  INVOLVEMENT  OF  THE  MIDDLE  PALMAR 
AND  THENAR  SPACES. 

The  treatment  here  can  be  best  illustrated  by  quot- 
ing a  typical  case.  Here  the  middle  palmar  and  the 
thenar  spaces  having  been  simultaneously  involved, 

FIG.  100 


Drawing  showing  the  drainage  under  tendons.  AT,  adductor  transversus; 
LS,  lumbrical  space;  MPS,  middle  palmar  space;  TS,  thenar  space;  UB, 
ulnar  bursa. 

the  forceps  was  passed  from  the  incision  into  the  middle 
palmar  space  under  the  palmar  tendons,  as  already 
described,  and  pushed  through  the  thin  septum  sepa- 
rating the  palmar  and  thenar  spaces  at  the  proximal 


294     TREATMENT'  OF  F ASCI AL-SP ACE  ABSCESSES 

end,  the  point  thus  passing  through  the  thenar  space 
superficial  to  the  adductor  transversus  and  coming  out 
on  the  dorsum  between  the  metacarpal  bones  of  the 
thumb  and  index  finger  (Fig.  100).  A  gutta-percha 
drainage  strip  was  then  drawn  through  and  left 
eighteen  hours. 

CASE  XVI. — Primary  infection,  cracks  from  callus  on 
palm,  extension  into  palm  of  hand,  drainage  of  middle 
palmar  space,  thenar  space,  ulnar  bursa,  and  forearm. 
Recovery  with  perfect  function. 

H.,  Post-Graduate  Hospital.  Two  weeks  before  com- 
ing to  the  hospital  patient  had  developed  an  infection 
in  the  palm  of  the  hand,  evidently  in  the  callus  produced 
by  tongs  handling  ice.  Two  or  three  inadequate  incisions 
had  been  made  when  the  patient  entered  the  hospital, 
with  a  temperature  of  102°  and  an  enormous  swelling  of 
the  entire  hand  and  forearm,  involving  the  palmar  and 
dorsal  surfaces.  The  palmar  fascia  bulged  up  instead  of 
presenting  its  normal  concavity,  while  the  thenar  area  was 
ballooned  out  as  if  inflated  to  its  complete  capacity. 
There  was  redness  and  swelling  upon  the  flexor  surface  of 
the  forearm  involving  particularly  the  lower  third.  The 
swelling  upon  the  back  of  the  hand  was  ascribed  to  edema. 
The  fingers  were  flexed  at  an  angle  of  45  degrees,  while  the 
metacarpal  bone  of  the  thumb  set  back  from  the  hand  and 
the  distal  phalanx  of  the  thumb  was  sharply  flexed.  The 
diagnosis  of  pus  in  the  middle  palmar  space,  thenar  space, 
the  forearm  under  the  profundus  tendons,  and  the  probable 
involvement  of  the  common  synovial  sheath  in  the  palm 
was  made.  Owing  to  the  inadequate  incision  already  made 
in  the  palm,  this  was  chosen  as  the  proper  site  for  explor- 
ation. The  incision  having  been  carried  through  the 
palmar  fascia,  pus  was  found  in  the  position  designated, 
with  an  involvement  of  the  ulnar  bursa  from  the  base  of  the 
little  finger  to  the  forearm.  The  bursa  was  opened  through- 
out its  length,  cutting  through  the  anterior  annular  liga- 
ment. The  major  portion  of  the  pus,  however,  lay  outside 
the  sheath.  An  artery  forceps  was  inserted  under  the 
tendons  of  the  palm  below  the  sheath  and  a  large  ostium 
made.  An  artery  forceps  was  then  thrust  through  the 


TREATMENT  OF  PALMAR  AND  THENAR  SPACES    295 


FIG.  101 


Case  XVI  before  and  after  incision, 
from  the  dorsum  into  the  thenar  space, 
ligament  was  cut. 


Note  the  artery  forceps  through 
In  this  case  the  anterior  annular 


296     TREATMENT  OF  F ASCI AL-SP ACE  ABSCESSES 

partition  between  the  thenar  and  middle  palmar  spaces 
at  the  base  of  the  hand  lying  on  the  volar  side  of  the  trans- 
versus  pollicis,  coming  out  between  the  metacarpal  bones 

FIG.  102 


Case  XVI,  showing  result  three  months  after  treatment.    Note  perfect 

function. 


of  the  thumb  and  index  finger.  A  drainage  strip  was  then 
drawn  through  this  space  of  the  palm  and  left  in  eighteen 
hours.  The  incision,  which  was  carried  through  the 
anterior  annular  ligament  to  the  forearm,  exposed  a  large 


THE  PALMAR  AND  SUBAPONEUROTIC  SPACES    297 

abscess  lying  underneath  the  tendons  of  the  flexor  pro- 
fundus  digitorum  upon  the  pronator  quadratus  and 
interosseous  membrane.  The  incision  was  extended  for 
three  inches  up  on  the  forearm  to  open  this  space  com- 
pletely. Hot  boric  dressings  were  applied. 

Course. — Immediate  subsidence  of  temperature  and 
septic  symptoms.  In  ten  days  complete  cessation  of 
discharge,  and  in  two  weeks  all  wounds  were  healed.  In 
three  weeks  the  patient  was  using  his  hand  with  75  per 
cent,  of  function,  and  in  five  weeks  complete  function  was 
present,  as  demonstrated  by  accompanying  photographs 
(Figs.  101  and  102). 

This  case  was  one  of  the  worst  that  ever  came  to 
my  notice.  We  were  fortunate,  however,  in  that  no 
necrosis  of  the  tendons  had  taken  place.  The  rapid 
and  complete  recovery  can  be  ascribed  only  to  the 
thorough  opening  of  every  pocket  of  pus  by  incisions 
that  did  not  endanger  previously  uninvolved  areas.  We 
should  also  note  that  the  annular  ligament  was  cut. 


THE  TREATMENT  OF  COMBINED  INVOLVEMENT  OF  THE  MIDDLE  PALMAR 
AND  SUBAPONEUROTIC  SPACES. 

At  times  we  will  have  crushing  injuries  of  the  hand 
in  which  the  metacarpal  bones  are  fractured.  Here  the 
subaponeurotic  space  on  the  dorsum  is  involved  in  con- 
junction with  the  middle  palmar  space  (Case  VIII).  In 
such  cases  the  through-and-through  drainage  so  much 
in  vogue  among  the  older  surgeons  is  indicated.  Let 
us  study  where  such  drainage  can  be  safely  instituted 
if  it  is  indicated.  Such  a  point  should  be  chosen  as 
will  give  the  most  satisfactory  outlet  to  all  the  diver- 
ticula,  and  at  the  same  time  injure  the  fewest  structures. 
Here  the  value  of  our  x-ray  plates,  with  the  cross- 
sections  and  injections,  is  invaluable.  We  see  that  the 
mass  always  lies  over  the  interosseous  space  between 


298     TREATMENT  OF  F ASCI AL-SP ACE  ABSCESSES 

the  ring  and  middle  fingers,  and  that  an  opening  here 
will  drain  all  the  pockets  (Fig.  103).  Our  incision, 
however,  must  lie  proximal  to  the  superficial  trans- 
verse ligament.  (See  cross-section,  Fig.  68;  x-ray, 
Fig.  105.)  Secondly,  it  must  lie  to  the  radial  side  of 
the  ulnar  bursa  (x-ray  plate,  Fig.  104),  and  must  be  to 

FIG.  103 


X-ray  plate  made  from  a  hand  in  which  the  middle  palmar  space  was 
injected  with  a  mixture  of  red  lead  and  plaster  of  Paris.  Photograph  repre- 
sents location  of  pus  in  typical  middle  palmar  space  infection. 


the  ulnar  side  of  the  middle  metacarpal,  or  it  will 
enter  the  thenar  space.  This  again  throws  the  incision 
into  the  metacarpal  space,  between  the  middle  and 
ring  fingers.  Thus  we  see  that  not  only  are  the  fewest 
structures  injuced  at  this  site,  but  also  the  most  perfect 
drainage  is  instituted. 


THE  PALMAR  AND  SUBAPONEUROTIC  SPACES    299 

Now  let  us  consider  where  an  incision  should  lie 
in  this  space.  An  examination  of  the  x-ray  picture 
(Fig.  105)  shows  the  deep  palmar  arch  running  across 
this  area,  at  the  upper  end;  the  fine  lines  drawn  trans- 
versely represent  the  dense  transverse  ligament  while 
the  curved  lines  represent  the  palmar  creases.  It  is  thus 

FIG.  104 


X-ray  plates,  representing  the  location  of  pus  in  the  thenar  space,  with  its 
relation  to  the  ulnar  bursa. 


seen  that  at  the  point  where  the  middle  palmar  crease 
crosses  the  metacarpal  space  should  be  the  indicated 
site  for  drainage.  Making  a  cut  here  through  the  palmar 
aponeurosis,  and  then  forcing  a  pointed  artery  forceps 
through  to  the  dorsum,  being  careful  to  rupture  the 
dorsal  aponeurosis  freely,  we  draw  through  a  large 
twisted  gutta-percha  strip.  At  this  site  there  is  little 


300     TREATMENT  OF  F ASCI AL-SP ACE  ABSCESSES 

danger  of  a  pressure  necrosis  of  the  ulnar  bursa  or  the 
palmar  arches. 

FIG.  105 


X -ray  Plate. — Boundaries  of  the  thenar  and  middle  palmar  spaces  marked, 
and  proper  site  for  opening  the  latter  indicated.  Ulnar  bursa  and  blood- 
vessels injected.  Photograph  made  for  me  by  Miss  Brindley  's  Surgical  X-ray 
Laboratory.  MPS,  middle  palmar  space;  A,  deep  palmar  arch;  B,  thenar 
space. 


v  rr 

, 

TREATMENT  OF  ABSCESSES  IK  TffENAR  SPACE      301 

-"Fttrjijr 

TECHNIQUE  OF  TREATMENT  OF  ABSCESSES  IN  THE 
THENAR  SPACE. 

Should  the  thenar  area  be  involved,  the  indications 
for  radical  operation  are  absolute,  even  upon  less 
evidence  than  in  the  case  of  palmar  infection,  since 
here  the  dangers  of  delay  are  greater,  and  the  conse- 
quences of  opening  the  space,  even  though  uninfected, 
are  not  serious  (see  Case  VI,  in  which  space  was 
opened  when  uninfected,  under  mistaken  diagnosis). 
Here  the  pus  lies  either  anterior  to  the  adductor 
transversus,  or  upon  both  its  dorsal  and  palmar 
surface.  Theoretically,  the  most  available  place  to 
open  would  lie  to  the  radial  side  of  the  index  meta- 
carpal,  where  a  free  incision  would  drain  both  in  front 
of  and  behind  the  adductor.  We  therefore  make  an 
incision  through  the  dorsum,  on  the  radial  side  of  the 
index  metacarpal  and  opposite  its  middle,  and  on  a 
level  with  its  flexor  surface.  An  artery  forceps  is  then 
thrust  into  the  thenar  space  across  the  flexor  surface 
of  the  index  metacarpal.  This  gives  perfect  drainage 
and  leaves  no  scar  upon  the  flexor  surface  of  the  hand. 
Care  should  be  taken  not  to  pass  the  artery  forceps 
beyond  the  middle  metacarpal  bone,  for  fear  of  spread- 
ing the  infection  to  the  middle  palmar  space  (Fig. 
106). 

Illustrating  these  facts,  the  following  case  may  be 
cited : 

CASE  XVII. — K.,  injured  September  3,  1904.  The 
sharp  point  of  a  meat  tongs  ran  into  the  thenar  area  upon 
the  level  of  the  extended  thumb  about  2  cm.  from  the  thenar 
adductor  crease.  Pain  and  swelling  ensued  the  following 
day.  On  September  5,  he  consulted  a  physician,  who 
found  much  redness  and  swelling  upon  the  dorsal  thenar 
area  and  made  an  incision  there,  but  evidently  failed  to 
evacuate  pus.  Hot  dressings  were  applied,  and  two  days 


^F ASCI  AL-SP  ACE  ABSCESSES 

,UMQIS 

slater  patient  presented  himself  at  the  Northwestern  Uni- 
versity Surgical  Dispensary  for  treatment.  There  was 
considerable  swelling  of  the  whole  hand,  but  distinctly 
greater  upon  the  radial  side.  Dorsal  thenar  area  had 
slightly  greater  swelling  present  than  palmar  thenar  area. 
Upon  inspection  it  was  not  difficult  to  see  that  the  thenar 

FIG.  106 


Showing  incisions  made  upon  the  dorsum  of  the  hand.  That  upon  the 
thenar  space  is  made  to  drain  the  thenar  space  in  the  palm.  Those  upon 
the  distal  part  are  made  to  drain  extensions  from  the  palmar  space  to  the 
dorsum  and  the  so-called  collar-button  abscesses  when  they  extend  to  the 
dorsum. 

area,  as  a  whole,  was  much  more  swollen  than  the  re- 
mainder of  the  hand.  Adduction  thenar  crease  was  the 
dividing  line.  Thumb  metacarpal  fully  abducted,  proximal 
phalanx  semiflexed,  distal  phalanx  fully  flexed,  giving  an 
almost  spastic  look  to  the  hand.  The  finger  phalanges 
were  all  semiflexed.  The  flexion  of  the  index  finger, 


ABSCESSES  IN  SUBAPONEUROTIC  SPACE         303 

however,  was  more  rigid  than  that  of  the  other  three,  and 
movement  of  it  and  the  thumb  caused  more  pain  than 
the  three  ulnar  fingers.  Both  epitrochlear  and  axillary 
glands  slightly  enlarged  and  tender.  Old  incision  upon 
dorsal  thenar  region,  from  which  small  amount  of  pus 
was  exuding.  Temperature,  101  °;  pulse,  90.  Tenderness 
marked  over  palmar  thenar  area. 

Diagnosis. — Abscess,  thenar  space.  Operation:  Under 
nitrous  oxide  anesthesia  incision  made  into  thenar  area 
at  about  the  same  site  as  the  wound;  much  pus  evacuated. 
Gutta-percha  drainage  established;  hot,  moist  boric  dress- 
ings applied.  September  7,  swelling  almost  subsided,  still 
discharge  of  much  pus.  Temperature,  99°;  pulse,  84. 
Treatment  continued.  Cultures  taken;  typical  staphy- 
lococcus  aureus  colonies,  methylene  blue  and  Gram's 
stains;  staphylococcus  aureus.  September  9,  hand  much 
better,  drainage  removed,  hot  dressings  reapplied.  Sep- 
tember II,  hand  in  good  condition;  dry  dressings  applied. 
Following  this,  patient  made  a  rapid  recovery.  Seen  July, 
1905.  No  contraction;  function  perfect. 


TECHNIQUE  OF  TREATMENT  OF  ABSCESSES  IN   SUB- 
APONEUROTIC SPACE. 

If  the  subaponeurotic  space  be  involved,  we  should 
remember  that  the  tendons  proper  in  the  lower  part 
of  the  dorsum  overlie  the  metacarpal  bones,  except  the 
tendon  going  to  the  little  finger;  consequently  our 
incision  should  lie  over  the  interosseous  space.  More- 
over, any  deep  transverse  incision,  if  too  long,  would 
cut  the  tendon,  while  a  simple  longitudinal  incision 
would  tend  to  close.  Therefore,  in  making  our  incision 
and  drainage,  these  two  factors  should  be  taken  into 
consideration  and  an  adequate  opening  provided,  which 
does  not  injure  the  tendon.  Those  cases  complicated 
with  middle  palmar-space  infection  have  already  been 
discussed  (p.  297). 

//  the  infection  has  spread  up  under  the  annular 
ligament  into  the  forearm,  the  pus  will  lie  beneath  the 


304     TREATMENT  OF  FASCIAL-SPACE  ABSCESSES 

tendons  of  the  flexor  profundus  and  upon  the  pronator 
quadratus.  The  best  method  of  emptying  this  abscess 
would  be  to  go  laterally,  just  anterior  to  the  radius  and 
ulna  about  three  inches  from  the  wrist.  A  complete 
description  of  the  method  of  treating  these  cases  will 
be  found  in  Chapter  XXVII. 

AFTER-TREATMENT  IN  FASCIAI^SPACE  ABSCESSES. 

After  any  of  these  procedures  the  usual  hot,  moist 
dressings  are  applied  until  we  feel  that  extension  of  the 
process  has  ceased,  when  they  should  be  abandoned, 
since  the  continuation  of  the  enlargement  of  the  vessels 
incident  to  their  use  results  in  increasing  edema  and 
ultimately  lessening  resistance,  owing  to  improper  cir- 
culation; hence  they  become  a  menace  to  the  part 
rather  than  a  help.  At  this  stage  elevation  of  the  part 
will  be  found  to  be  of  material  aid.  Immobilization 
should  be  kept  up  as  long  as  there  is  any  danger  of 
muscular  action  disseminating  the  infection.  As  soon 
as  this  stage  has  passed,  however,  active  and  passive 
movements  should  be  encouraged  at  once,  with  the 
idea  of  assisting  in  the  absorption  of  the  excessive 
edema,  as  well  as  assisting  in  the  prevention  of  tendon 
and  joint  adhesions.  I  frequently  begin  these  on  the 
third  day. 


CHAPTER  XVIII. 

RESUME  OF  ACUTE  SUPPURATIVE  TENO- 

SYNOVITIS  AND   FASCIAL-SPACE 

ABSCESSES— PROGNOSIS. 

RESUME. 

SUCCESS  in  the  treatment  of  tendon-sheath  infections 
of  the  hand  depends  „  upon  early  accurate  diagnosis 
upon  incisions  so  made  as  to  drain  the  proper  sites 
without  involving  uninfected  areas,  and  upon  careful 
after-treatment. 

Two  types  must  be  recognized,  the  fulminating  and 
the  subacute.  The  treatment  will  vary  with  the  type. 
The  most  marked  symptoms  and  signs  are :  Localized 
excruciating  tenderness  over  the  course  of  the  sheath, 
pain  on  extension,  especially  at  the  proximal  end  of  the 
sheath,  and  the  characteristic  position  of  the  finger. 

Infection  from  the  tendon  sheath  of  the  index  finger 
will  most  often  extend  to  the  lumbrical  spaces  and  the 
thenar  space  and  less  often  to  the  proximal  interpha- 
langeal  joint,  and  the  surface  at  the  proximal  end  of 
the  sheath. 

From  the  middle  finger  it  most  often  extends  to  the 
lumbrical  spaces  and  middle  palmar  spaces  or  at  times 
the  thenar  space  and  less  often  to  the  proximal  inter- 
phalangeal  joint,  and  the  surface  at  the  proximal  end. 

From  the  ring  finger  the  extensions  are  the  same, 
except  that  they  always  involve  the  middle  palmar  space 
if  extension  takes  place  into  the  palm. 

From  the  little  finger,  the  most  common  sites  of  exten- 
sion are  the  lumbrical  space,  the  middle  palmar  space, 
and  the  ulnar  bursa,  less  commonly  to  the  proximal  inter- 
phalangeal  joint  and  the  surface  at  the  proximal  end 

20 


306     TENOSYNOVITIS  AND  FASCIAL-SPACE  ABSCESSES 

of  the  sheath.  From  the  ulnar  bursa  it  may  extend 
to  the  middle  palmar  space,  radial  bursa,  interosseous 
space  below  the  flexor  profundus,  and  the  wrist-joint. 
From  the  sheath  of  the  flexor  longus  pollicis  to  the 
thenar  space,  ulnar  bursa,  wrist-joint,  and  inter- 
osseous  space  above  described. 

Incisions  should  be  too  radical  rather  than  too 
conservative.  Incisions  are  best  made  in  the  fingers, 
either  upon  one  or  both  sides  of  the  tendon  sheath 
over  the  length  of  the  shaft  of  the  middle  and  proximal 
phalanx,  avoiding  the  joints,  and  into  the  proximal  end 
of  the  sheaths  or  the  lumbrical  spaces  to  provide  drain- 
age there.  Complete  splitting  along  one  side  should  be 
done  in  case  of  doubt,  since  the  adequacy  of  drainage 
should  be  the  first  requisite. 

The  ulnar  bursa  is  best  treated  by  splitting  it 
throughout  its  length,  cutting  upon  the  ulnar  side. 
The  anterior  annular  ligament  may  be  cut  if  necessary. 
This  is  commonly  supplemented  by  incisions  upon  the 
radial  and  ulnar  sides  of  the  forearm  above  the  wrist- 
joint,  and. on  a  level  with  the  flexor  surface  of  the  bones; 
through-and-through  drainage  is  then  carried  out 
under  the  flexor  profundus  tendons.  An  ulnar  incision 
may  be  sufficient.  If  the  pus  has  invaded  the  forearm, 
an  ulnar  incision  is  made  at  the  middle  of  the  forearm 
between  the  flexor  carpi  ulnaris  and  the  flexor  sub- 
limis,  or  between  the  flexor  carpi  ulnaris  and  the  ulna. 

Incision  of  the  flexor  longus  pollicis  sheath  is  made 
from  a  finger-breadth  below  the  anterior  annular  liga- 
ment to  the  end  of  the  sheath.  Opening  may  be  made 
above  the  anterior  annular  ligament,  the  upper  half 
of  which  may  be  cut.  However,  drainage  may  be 
better  instituted  above  the  wrist  by  the  lateral  incision 
mentioned  under  ulnar  bursal  infections. 

In  the  after-treatment  the  Bier  constrictor  may  be 
used  for  a  few  hours,  hot,  moist  dressings  for  from  two 


PROGNOSIS  307 

to  four  days,  followed  by  dry  dressings,  the  hand  being 
held  in  overextension  by  splint  and  daily  manipulation  of 
joints  and  muscles  after  immediate  danger  of  systemic 
infection  has  ended. 

There  may  be  accumulations  of  pus  in  any  of  the 
six  fascial  spaces  I  have  described,  to  the  exclusion  of 
any  or  all  the  others,  namely,  the  middle  palmar, 
thenar,  lumbrical,  hypothenar,  dorsal  subaponeurotic, 
dorsal  subcutaneous.  These  may  be  involved  separ- 
ately or  in  conjunction  with  the  tendon  sheaths.  The 
middle  palmar  space  with  its  diverticula  along  the  three 
lumbrical  muscles  is  best  drained  by  an  incision  along 
a  lumbrical  canal  carried  up  to  the  space.  The  thenar 
space  is  best  drained  by  an  incision  on  the  dorsum  to 
the  radial  side  of  the  index  metacarpal.  Hypothenar 
abscesses  are  localized  and  can  be  drained  by  simple 
incision.  All  forearm  extensions  may  be  drained  by 
lateral  incisions  above  the  wrist,  the  drainage  being 
inserted  under  the  tendons  of  the  flexor  profundus 

digitorum. 

PROGNOSIS. 

The  life  of  the  individual  is  frequently  jeopardized 
in  either  of  these  types  of  infections.  Undoubtedly  if 
proper  treatment  is  instituted  the  danger  will  be 
reduced  to  a  minimum.  The  lymphatic  infections 
which  will  be  discussed  in  the  subsequent  chapters  are 
the  most  frequent  source  of  death.  The  fulminating 
type  of  tendon-sheath  infections  may  cause  death,  but 
the  more  chronic  type,  as  also  the  fascial  space  abscesses, 
should  have  few  fatalities  except  in  neglected  cases. 
Especial  caution  should  be  exercised  in  giving  a  favor- 
able prognosis  in  the  aged,  since  the  prognosis  grows 
rapidly  worse  after  forty.  The  presence  of  a  nephritis 
is  also  of  serious  import. 

It  is  very  nearly  impossible  to  state  from  a  study  of 
the  literature  what  proportion  of  cases  may  hope  for 
a  satisfactory  local  outcome.  The  authors  base  their 


308     TENOSYNOVITIS  AND  FASCIAL-SPACE  ABSCESSES 

statistics  upon  different  classifications.  "Good  result" 
is  used  by  some  to  designate  a  recovery  without  loss 
of  any  part  of  the  hand,  with  function  at  the  wrist  and 
in  the  uninvolved  fingers,  while  others  insist  upon  a 
complete  restoration  of  the  function  in  the  finger  as 
well.  It  is  to  be  hoped  that  in  the  future  the  statistics 
may  be  more  accurate.  From  my  personal  experience, 
however,  I  feel  that  the  following  statements  may  be 
made.  A  complete  functionating  hand  can  always  be 
promised  in  acute  infections  of  the  hand,  not  involving 
the  tendon  sheaths,  unless  necrosis  of  tissue  has  taken 
place  or  joint  involvement  has  occurred.  That  is  to  say, 
abscesses  of  the  middle  palmar  space,  thenar  space,  and 
forearm,  as  well  as  simpler  conditions,  can  be  treated 
with  a  perfect  functionating  result.  This  has  occurred 
in  my  experience  even  after  four  or  five  weeks  of  in- 
adequate treatment.  In  tendon-sheath  infection,  how- 
ever, the  results  are  not  nearly  so  good.  By  proper 
and  early  treatment  a  perfect  result  can  generally  be 
assured  as  to  function  of  the  wrist-joint,  hand  and 
fingers  not  involved.  Where  the  tendon  sheath  of  a 
finger  is  involved,  unless  early  treatment  is  instituted, 
flexion  of  the  phalanges  of  that  finger  is  likely  to  be 
lost,  while  flexion  at  the  metacarpophalangeal  articu- 
lation may  generally  be  preserved.  In  early  cases  or 
under  exceptional  circumstances  complete  function  may 
be  secured.  In  the  thumb,  even  though  the  function 
of  the  flexor  longus  pollicis  is  lost,  the  hand  will  not 
be  seriously  impaired,  since  the  smaller  muscles  of  the 
thumb  will  give  it  such  function  that  the  impairment 
will  not  be  as  serious  by  any  means  as  in  the  fingers. 
Extension  from  tendon  sheaths  to  the  forearm  should 
be  looked  upon  with  anxiety,  and  if  serious  complica- 
tions or  sequelae  are  present,  the  patient  must  be 
warned  that  the  course  may  be  long  and  the  ultimate 
restoration  of  function  depend  much  upon  continued 
and  faithful  application  of  after-treatment. 


SECTION   III. 
LYMPHATIC  INFECTIONS. 


CHAPTER    XIX. 

THE  RELATION  OF  LYMPHANGITIS  TO 
OTHER  TYPES  OF  INFECTION— DIS- 
CUSSION OF  THE  ANATOMY. 

THE  RELATION  OF  LYMPHANGITIS  TO  OTHER  TYPES  OF 
INFECTION.   - 

LYMPHANGITIS  may  be  of  two  types,  superficial  and 
deep.  Of  these,  the  superficial  is  most  common,  owing 
to  the  fact  that  slight  abrasions,  superficial  fissures,  and 
small  punctures,  disregarded  by  the  patient  because 
they  are  considered  of  no  importance,  are  generally 
the  source.  These  lie  in  the  superficial  tissues  and 
lead  to  a  superficial  or  subcutaneous  infection.  The 
rarer  type,  deep  lymphangitis,  undoubtedly  may  occur. 
When  it  does,  however,  it  develops  as  a  complication 
of  superficial  lymphangitis  or  as  a  sequence  of  deep 
injury,  and  when  such  deep  injury  occurs  the  wound  is 
generally  considerable,  so  that  the  lymphangitis  is  of 
secondary  importance  to  the  local  condition. 

For  the  sake  of  study,  lymphangitis  must  be  sharply 
differentiated  from  tenosynovitis  and  fascial  space  in- 
fection. It  is  true  that  in  a  large  number  of  cases  a 
tenosynovitis  or  fascial-space  infection  may  develop 
from  a  lymphangitis,  but  it  is  also  true  that  in  a 
majority  of  cases  neither  complication  ensues  unless 
ill-advised  surgery  produces  them.  Under  patho- 


genesis  I  shall  discuss  these  complications  in  full,  and 
under  symptomatology  shall  try  to  suggest  the  various 
points  which  may  serve  to  differentiate  them  when 
they  are  separate  conditions  or  may  serve  to  diag- 
nosticate their  development  when  they  arise  in  the 
course  of  a  pure  lymphatic  infection.  Owing  to  the 
intimate  relation  of  lymphangitis  to  septicemia,  it  has 
seemed  wise  to  associate  the  discussion  of  the  former 
with  that  of  the  latter,  and,  for  the  sake  of  the  clinical 
picture,  to  consider  in  relation  to  them  the  various 
severe  infections  jeopardizing  life,  such  as  gas  bacillus 
infections  and  anthrax.  A  complete  discussion  of  teno- 
synovitis  and  fascial-space  abscesses  may  be  found  in 
the  preceding  chapters. 

ANATOMY. 

In  order  to  understand  the  pathogeny  of  lymphatic 
abscesses,  an  accurate  knowledge  of  the  position  and 
course  of  the  lymphatic  vessels  is  absolutely  essential. 
The  masterful  work  of  Mascagni  and  the  later  work 
by  Sappey  have  been  fully  reviewed  and  verified  by 
Poirier,  with  the  assistance  of  his  pupil  Cuneo,  making 
use  of  Gerota's  process  of  injection,  and  the  following 
is  largely  quoted  from  their  treatise  upon  that  subject. 
We  so  often  see  the  superficial  lymphatics  in  the  course 
of  surgical  practice  that  we  are  inclined  to  forget  that 
there  are  deep  lymphatics  which  follow  the  deeper 
vessels.  Sappey  believed  that  these  two  systems  were 
absolutely  independent.  Poirier,  however,  maintains 
that  communication  is  fairly  common,  especially  in 
the  articular  regions.  It  is  important  to  remember 
that  the  principal  vessels  and  glands  lie  superficial  to 
the  large  veins  and  seldom  deep.  The  clinical  signifi- 
cance of  this  is  apparent  to  the  surgeon.  Another 
general  point  of  importance  is  that  the  texture  of  the 


ANATOMY 


311 


surrounding  connective  tissue  influences  their  shape  and 
number.  If  the  connective  tissue  is  lax,  their  tendency 
is  to  run  together  and  become  sinuous  and  sacciform 
(Fig.  107).  Consequently  the  infection  is  likely  to 

FIG.  107 


•     -CK 


m 


V^V^Hp'- 

Drawing  showing  lymphatics  grouped  about  a  hair  follicle  on  the  dorsum. 
Character  of  lymphatic  tissue  commonly  seen  in  loose  connective-tissue  spaces. 
(After  Sappey.) 


312    LYMPHANGITIS  AND  OTHER  TYPES  OF  INFECTION 

localize  in  the  looser  connective-tissue  areas.  This 
probability  is  accentuated  by  the  fact  that  glands, 
either  microscopic  or  macroscopic,  show  a  predilection 
for  these  areas.  The  fact  that  sacciform  dilatations 
and  microscopic  glands  do  occur  explains  the  produc- 
tion of  abscesses  in  the  course  of  an  apparently  un- 
interrupted lymphatic.  Moreover,  the  variability  both 
in  the  number  and  the  position  of  these  glands  renders 
absolute  statements  as  to  their  position  impossible. 
Not  alone  are  microscopic  glands  present  in  the  course 
of  the  vessels;  Gulland  has  demonstrated  them  in 
the  axilla,  and  Stiles  has  seen  axillary  glands  appear 
during  lactation  and  disappear  on  its  cessation.  How- 
ever, this  may  be  stated:  In  a  given  animal  and  a 
given  region  the  quantity  of  glandular  tissue  is  always 
practically  identical.  Thus  if  the  glands  are  small 
they  are  numerous,  and  if  large  they  are  likely  to  be 
scarce.  In  any  case,  however,  they  are  generally 
paravascular. 

THE  LYMPHATIC  VESSELS  OF  THE  HAND  AND  FOREARM. 

These  may  be  divided  into  two  groups — the  super- 
ficial lymphatics,  which  arise  from  the  integument 
and  whose  collecting  trunks  run  in  the  subcutaneous 
cellular  tissue,  and  the  deep  lymphatics,  arising  in  the 
deeper  tissues  and  in  vessels  following  the  deep  blood- 
vessels. 

SUPERFICIAL  LYMPHATICS. 

These,  being  easily  demonstrated  experimentally  and 
seen  so  often  clinically,  are  well  known. 

"The  superficial  lymphatics  come  from  all  parts  of 
the  cutaneous  covering  of  the  limb,  but  it  is  in  the 
fingers  (Fig.  108)  and  the  palm  of  the  hand  that  the 
net-work  of  origin  is  the  richest.  It  is,  therefore,  at 


SUPERFICIAL  LYMPHATICS  313 

these  points,  and  more  particularly  on  the  palmar 
surface  of  the  fingers,  that  punctures  must  be  made 
for  the  injection  of  the  lymphatics  of  the  upper  limb. 
"The  collecting  trunks  of  the  superficial  net-work 
appear  at  the  roots  of  the  fingers  and  at  the  base  of 
the  palm  of  the  hand  (Fig.  109).  They  then  run  up- 
ward on  the  forearm  and  arm,  receiving  as  they  ascend 
the  lymph  from  other  parts  of  the  cutaneous  covering. 
They  terminate  in  the  glands  of  the  axilla.  We  will 
study  first  their  digital  and  palmar  origin,  and  then 
their  course  and  termination. 

FIG.  108 


Net-work  of  lymphatics  on  the  side  of  the  finger.  The  accompanying 
drawing  represents  the  trunklets  which  carry  the  lymphatic  stream  to  the 
base  of  the  finger.  (After  Sappey.) 

"Origins:  (A)  In  the  fingers,  the  net- work  of  origin 
presents  its  maximum  of  development  on  the  palmar 
surface  (Fig.  no).  Here  the  meshes  are  so  closely 
set  that  it  is  only  by  a  careful  examination  with  a 
lens  that  they  can  be  distinguished.  The  dorsal  net- 
work is  much  less  rich  than  the  preceding  (Fig.  in). 
From  these  two  net-works  arise  a  considerable  number 
of  collectors,  which  converge  toward  the  sides  of  the 
fingers  and  unite  to  form  two  or  three  trunks  on  each 
of  these  surfaces  (Fig.  108).  These  trunks  at  first 


314    LYMPHANGITIS  AND  OTHER  TYPES  OF  INFECTION 


FIG.  109 


Showing  lymphatics  of  a  hand  and  arm,  the  areas  of  origin  and  distribution. 

(After  Sappey.) 


SUPERFICIAL  LYMPHATICS 


315 


FIG.  no 


Showing  extensive  net-work  of  lymphatic  channels  on  the  palm  and  fingers, 
with  their  extensions  to  the  dorsum  and  to  the  forearm  through  the  collecting 
trunklets.  (After  Sappey.) 


316    LYMPHANGITIS  AND  OTHER  TYPES  OF  INFECTION 

follow  the  corresponding  collateral  artery,  but,  having 
arrived  at  the  base  of  the  finger,  they  incline  backward 


FIG.  in 


Showing  lymphatics  upon  the  dorsum.     Note  how  few  there  are  in  com- 
parison with  those  upon  the  palmar  surface.     (After  Sappey.) 

and  run  toward  the  interdigital  space.  They  then  pass 
to  the  posterior  surface  of  the  hand,  and  are  directed 
toward  the  wrist,  where  we  shall  trace  them  again 


SUPERFICIAL  LYMPHATICS  317 

shortly.  In  their  course  on  the  dorsal  surface  of  the 
hand  they  effect  numerous  anastomoses.  They  cross 
one  another  frequently,  and  it  is  no  unusual  thing  to 
see  a  collecting  trunk,  which  has  arisen,  for  example, 
in  the  fourth  interdigital  space,  uniting  with  trunks 
which  run  along  the  external  part  of  the  dorsal  surface 
of  the  hand. 

FIG.  1 1-2 


Lymphatic  vessels  of  the  palm,  showing  their  extensions  from  all  the 
borders  to  the  dorsum  and  the  extension  from  the  central  portion  into  the 
deep  lymphatic  along  the  palmar  arch.  (After  Sappey.) 

"  (B)  In  the  palm  of  the  hand  the  net- work  of  origin 
is  also  extremely  rich.  From  this  net- work  run 
numerous  trunklets,  which  we  may  divide  into  exter- 
nal, internal,  inferior,  superior,  and  central  (Fig.  112). 

'The  external  trunklets,  four  to  six  in  number,  run 
obliquely  upward  and  outward,  and,  crossing  the  sur- 
face of  the  thenar  eminence  in  a  slanting  direction, 
terminate  in  the  lymphatics  coming  from  the  integu- 
ments of  the  thumb. 

"The  internal  trunklets,  more  numerous  than  the 
preceding  (eight  or  ten),  run  almost  transversely 
inward,  and,  crossing  the  ulnar  border  of  the  hand, 


318    LYMPHANGITIS  AND  OTHER  TYPES  OF  INFECTION 

reach  the  dorsal  surface  and  empty  themselves  into 
the  collecting  trunks  which  arise  from  the  integument 
of  the  little  finger. 

"The  inferior  trunklets,  which  vary  from  twelve  to 
fifteen  in  number,  are  directed  toward  the  interdigital 
spaces;  they  then  reach  the  dorsal  surface  of  the  hand 
and  terminate  in  the  digital  collecting  trunks. 

'The  superior  trunklets  reach  the  anterior  surface 
of  the  wrist,  and  unite  to  form  three  or  four  trunks, 
which  ascend  on  the  anterior  surface  of  the  forearm. 

'The  central  trunklets  run  toward  the  deep  portion. 
They  traverse  the  subcutaneous  fatty  layer  and  the 
superficial  palmar  fascia,  and  they  usually  unite  into 
a  single  trunk.  The  latter,  which  has  been  well 
described  by  Sappey,  takes  the  following  course:  It 
is  directed  immediately  outward,  running  underneath 
the  fascia,  in  front  of  the  flexor  tendons.  It  thus  comes 
to  the  adductor  transversus  pollicis,  crosses  the  inferior 
border  of  this  muscle,  and  then  crosses  the  outer  border 
of  the  first  dorsal  interosseous,  on  the  posterior  surface 
of  which  it  ascends.  It  there  joins  collectors  coming 
from  the  index  finger,  and  in  company  with  the  latter 
reaches  the  dorsal  surface  of  the  wrist. 

"Course:  All  these  collecting  trunks,  which  arise 
from  the  integuments  of  the  fingers  and  hand,  run  in 
the  subcutaneous  cellular  tissue  toward  the  root  of 
the  limb.  They  are  usually  more  superficial  than  the 
veins  whose  trunks  they  cover.  They  diminish  in 
number  as  they  are  traced  upward.  In  the  forearm 
there  are  about  thirty,  but  in  the  middle  of  the  arm 
not  more  than  fifteen  to  eighteen.  (Sappey.) 

"In  the  wrist  they  are  divided  into  two  groups,  of 
which  one  runs  on  the  dorsal,  the  other  on  the  palmar 
surface  of  this  part  of  the  limb. 

"In  the  forearm  they  tend  to  divide  themselves 
into  three  groups — an  external  group,  which  ascends 


SUPERFICIAL  LYMPHATICS  319 

along  the  radial  border  of  the  forearm;  an  internal 
group,  which  follows  the  ulnar  border;  a  middle  group, 
which  is  a  satellite  of  the  median  vein  and  runs  between 
the  two  preceding. 

"A  little  below  the  bend  of  the  elbow  the  two  lateral 
groups  come  more  and  more  to  the  anterior  surface 
of  the  limb  and  unite  with  the  median  group;  on  the 
dorsal  surface  we  find  nothing  but  some  rather  small 
collecting  trunks,  which  incline  obliquely,  some  out- 
ward, others  inward,  and  reach  the  anterior  surface  of 
the  arm  (Fig.  109).  At  the  level  of  the  olecranon  these 
collecting  trunks  present  remarkable  sinuosities. 

"In  the  arm  the  different  collecting  trunks,  hence- 
forth united  into  a  single  bundle,  show  a  tendency  to 
arrange  themselves  on  the  external  surface  of  the  arm, 
parallel  to  each  other. 

"Termination:  The  majority  of  these  collectors  run 
as  far  as  the  neighborhood  of  the  base  of  the  axilla. 
Here,  they  perforate  the  deep  fascia  and  terminate 
in  the  humeral  chain  of  axillary  glands.  The  collectors 
from  the  outermost  and  innermost  parts  have  quite  a 
different  termination;  thus,  two  or  three  of  the  most 
internal  end  in  the  supra-epitrochlear  gland.  We  have 
already  seen  that  the  efferents  of  this  gland  perforated 
.the  deep  fascia  in  the  middle  part  of  the  arm  and  end 
in  the  deep  vessels.  When  this  gland  is  absent,  we  may 
nevertheless  see  the  internal  collectors  perforating  the 
fascia  at  the  same  point  to  reach  the  deep  absorbents. 
The  most  external  trunk  is  also  remarkable  for  the 
special  course  it  pursues.  It  separates  itself  from  the 
other  collectors  in  the  region  of  the  humeral  insertion 
of  the  deltoid,  then  ascends  in  the  deltopectoral  groove, 
where  it  may  traverse  one  or  several  glands  which  we 
have  indicated  above.  This  trunk  usually  passes  into 
a  subclavian  gland,  placed  at  the  spot  where  the 
cephalic  joins  the  axillary  vein.  It  may  also  be  seen 


320    LYMPHANGITIS  AND  OTHER  TYPES  OF  INFECTION 

to  pass  above  the  clavicle,  and  to  empty  itself  into  a 
supraclavicular  gland.  This  arrangement,  though 
somewhat  infrequent  (Grossmann  says  38  out  of  100 
cases),  has  been  figured  by  Mascagni.  This  delto- 
pectoral  trunk  is  sometimes  double  and  even  triple." 

DEEP  LYMPHATICS. 

"The  deep  lymphatics  follow  the  brachial  artery  and 
its  chief  branches.  There  are  usually  two  lymphatic 
trunks  for  each  artery.  With  Sappey,  we  will  divide 
these  deep  lymphatics  into  radial,  cubital,  posterior 
interosseous,  anterior  interosseous,  and  brachial. 

"The  radial  trunks  arise  from  the  subfascial  portions 
of  the  palm  of  the  hand.  'One  accompanies  the  deep 
palmar  arch,  turns  around  the  head  of  the  first  meta- 
carpal  bone,  and  runs  on  the  outer  side  of  the  carpus, 
and  reaches  the  forearm,  where  it  is  situated  on  the 
external  side  of  the  radial  artery;  the  other,  whose 
origin  is  not  so  deep,  follows,  according  to  the  sketch 
left  us  by  Mascagni,  the  course  of  the  radiopalmar 
artery,  and  also  joins  the  forearm,  where  it  is  placed 
on  the  inner  side  of  the  radial.  Both  then  ascend  as 
far  as  the  bend  of  the  elbow,  where  they  anastomose. 
In  their  antibrachial  course  they  traverse  one  or  two 
small  glands,  the  existence  of  which  is  not  constant.' 
(Sappey.) 

"The  ulnar  trunks  are  also  two  in  number.  They 
have  a  separate  origin.  One,  in  fact,  appears  by  the 
side  of  the  superficial  palmar,  while  the  other  is  a 
satellite  of  the  deep  palmar  arch.  They  unite  at  the 
wrist,  just  above  which  they  receive  a  large  affluent 
which  is  a  satellite  of  the  dorsal  branch  of  the  ulnar. 
They  then  run  parallel  to  the  ulnar  vessels  as  far  as 
the  bend  of  the  elbow.  During  their  course  they 
sometimes  present  one  or  more  small  glands. 

"The  posterior  interosseous  trunks,  which  arise  from 


DEEP  LYMPHATICS 


321 


the  deep  muscles  of  the  forearm,  perforate  the  inter- 
osseous  membrane  and  then  unite  at  the  bend  of  the 
elbow  with  the  preceding  vessels. 

"The  anterior  interosseous  trunks  follow  the  vessels 
of  this  name,  and,  after  presenting  in  their  course  one 
or  two  small  glands,  also  end  in  the  lymphatic  meeting- 
place  at  the  bend  of  the  elbow. 

FIG.  113 


Showing  lymphatics  about  a  hair  follicle.     (After  Sappey.) 

'The  humeral  trunks  comprise  all  the  above-men- 
tioned antibrachial  collecting  trunks.  They  vary  from 
two  to  three  in  number.  They  run  by  the  side  of  the 
humeral  vessels,  and  terminate  in  the  humeral  group 
of  the  axillary  glands.  As  we  have  already  seen,  they 
present  in  their  course  some  small  glands  which  appear 
to  be  nearly  always  present.  In  the  middle  part  of 
the  arm  they  collect  the  efferent  vessels  from  the 
supra-epitrochlear  gland.  They  also  receive  some  small 
trunks  from  the  muscles  of  the  arm," 


21 


CHAPTER    XX. 

LYMPHANGITIS— ETIOLOGY,  PATHOGENESIS, 
AND  PATHOLOGY. 

PREDISPOSING  AND  ACTIVE  FACTORS  IN   THE  PRODUCTION 
OF  LYMPHANGITIS. 

WHILE  a  lymphangitis  may  develop  at  any  time  of 
the  year,  it  is  most  frequently  observed  in  the  fall  and 
winter,  an  observation  that  is  concurred  in  by  all 
authors.  This  may  find  its  cause  in  the  unnatural 
conditions  under  which  workingmen  live  during  the 
colder  months,  at  which  time  they  are  closely  housed, 
with  the  result  that  they  breathe  impure  air,  and  be- 
cause of  this  and  the  lack  of  outdoor  exercise  their 
power  of  resistance  is  reduced.  It  is  possible  that  the 
colder  air  which  contracts  the  superficial  vessels  may 
have  some  bearing  on  the  development  of  the  infections 
by  lessening  the  natural  protection  against  superficial 
injuries. 

The  source  is  most  often  some  slight  puncture,  carry- 
ing bacteria  beneath  the  surface,  or  the  small  cracks 
so  often  found  in  workingmen's  hands,  especially  in 
winter,  about  the  calloused  areas,  the  so-called  durillon 
force  of  the  French  authors.  These  are  particularly 
noted  at  the  distal  part  of  the  palm,  where  dirt  incident 
to  the  occupation  is  rubbed  into  the  fissures.  The 
slight  punctures  often  come  from  needles  or  pins,  and 
are  thus  frequently  found  on  the  distal  phalanx,  gen- 
erally being  so  slight  as  to  have  been  forgotten  when 
the  patient  applies  for  treatment.  Again,  we  note  its 
frequency  after  trauma  of  the  nail.  The  patient  gives  a 
history  of  running  a  splinter  under  the  nail,  or  of  some 


FACTORS  IN  THE  PRODUCTION  OF  LYMPHANGITIS    323 

injury  which  has  caused  a  separation  of  the  nail  from 
its  bed,  with  a  small  subonychial  hemorrhage,  which 
has  become  infected. 

Why  it  is  that  similar  injuries  may  be  followed 
in  one  case  by  severe  lymphangitis  and  in  another  by 
no  results  is  still  an  unanswered  question.  We  are 

FIG.  114 


Showing  lymphatics  in  the  palm  of  the  hand.     (After  Sappey.) 

accustomed  to  say  that  the  resistance  of  the  patients 
varies,  and  this  is  undoubtedly  true.  On  the  other  hand, 
every  surgeon  has  seen  many  cases  of  severe  lym- 
phangitis in  patients  of  apparently  normal  resistance. 
We  cannot  attribute  the  cause  entirely  to  lessened 
resistance.  It  is  possible  that  some  bacteria  contain 


324  LYMPHANGITIS 

inherent  cytolytic  attributes  which  lessen  the  possi- 
bility of  the  walling-off  process  and  favor  extension. 
Many  investigators  have  studied  the  question  and 
added  individual  facts  to  our  knowledge,  which  is 
inadequate,  however,  for  a  complete  understanding  of 
the  subject.  Canon  showed  that  ligation  of  the  small 
intestine  favored  bacterial  growth  in  the  blood  stream, 
thus  showing  the  importance  of  proper  intestinal  action. 
He  also  thought  that  he  had  demonstrated  that  an 
excessive  acidity  of  the  blood  is  more  favorable  to 
bacterial  growth  than  any  alkalinity.  This,  however, 
has  not  been  verified. 

THE  INFLUENCE  OF  THE  TYPE  OF  GERM. 

It  is  probable  that  almost  any  of  the  various  patho- 
genic bacteria  may  give  rise  to  lymphatic  infection. 
In  a  great  majority  of  the  cases,  however,  the  strepto- 
coccus will  be  found  to  be  the  etiological  factor.  The 
virulence  of  both  streptococci  and  staphylococci  varies 
within  wide  limits,  and  even  the  same  organism  may  in 
successive  cultures  or  various  media  change  its  viru- 
lence. Many  attempts  have  been  made  to  classify 
the  bacteria  according  to  their  virulence,  but  without 
success.  On  the  other  hand,  certain  physiological 
processes  of  bacteria  have  been  studied  which  may 
in  time  lend  some  aid,  and  meanwhile  they  serve  to 
explain  some  of  the  phenomena  noted  in  infections. 
Among  the  most  marked  characteristics  of  severe 
infections  we  have  the  cytolytic  and  hemolytic  func- 
tions. The  semijaundiced  appearance  of  the  severe 
cases  due  to  the  hemolysis  is  a  well-known  picture,  and 
while  most  often  seen  with  streptococcus  infections, 
it  may  also  appear  in  the  staphylococcus  forms  to  a 
marked  degree,  especially  in  the  aureus  infections  and 
to  a  lesser  degree  in  the  albus.  This  staphylohemolysin 


THE  INFLUENCE  OF  THE  TYPE  OF  GERM   325 

must,  however,  be  present  in  considerable  amounts 
before  its  effects  become  apparent  in  man,  since  his 
serum  contains  normally  small  amounts  of  antista- 
phylolysin,  as  was  shown  by  Neisser,  and,  moreover,  if 
the  inoculation  or  infection  begins  slowly,  the  system 
will  develop  larger  amounts. 

This  hemolysis  is  particularly  marked  in  the  strep- 
tococcus infections,  where  the  pasty,  semi-yellow  ap- 
pearance in  the  fatal  cases  is  almost  constant.  This 
observation  was  discussed  by  Marmorek  in  1895, 
but  attempts  to  classify  the  virulence  of  the  types 
in  relation  to  it  have  failed,  since  many  avirulent 
forms  possess  the  same  property  as  shown  by  Schott- 
muller.  Fromme  thought  he  could  differentiate  these 
by  attempting  a  culture  on  a  media  of  lecithin  and 
bouillon,  in  that  the  lecithin  would  inhibit  the  growth 
of  the  more  pathogenic  forms,  and  that  through  this 
he  could  prognosticate  the  severity  of  any  infection 
and  thus  take  proper  steps  for  its  cure.  Unfortunately, 
subsequent  investigations  of  Sachs  and  others  have 
dispelled  these  hopes,  and  we  are  no  further  in  our 
knowledge  than  we  were.  Attempts  have  also  been 
made  to  classify  the  virulence  of  the  streptococci  by 
reference  to  the  length  of  the  chains.  Lingelsheim,  in 
1899,  first  employed  the  terms  streptococcus  "longus" 
and  "brevis."  The  more  virulent  types  in  man  are 
most  likely  to  be  found  in  the  long  chains.  No  absolute 
dependence,  however,  can  be  placed  upon  this  finding. 
Many  of  the  other  types  of  bacteria  may  be  found  in 
the  systemic  infections;  even  the  Bacillus  pyocyaneus 
has  been  found  in  a  number  of  cases,  as  instanced  by 
Roberts,  Finkelstein,  and  Brill  and  Libman. 

A  careful  study  of  the  effects  of  combined  bacterial 
infections  is  to  be  desired.  The  effect  of  symbiosis  is 
not  fully  known,  although  it  has  been  hinted  at  by 
various  authors.  The  effect  of  combined  streptococcus 


326  LYMPHANGITIS 

and  staphylococcus  involvement  is  of  special  interest, 
since  we  so  often  see  this  combination.  Fisher  and 
Levy  suggest  that  the  streptococus  through  its  rapid 
spread  prepares  the  soil  for  the  staphylococcus.  When 
this  occurs  the  prognosis  is  more  grave,  since  the  com- 
bination seems  to  increase  the  virulence  of  the  strepto- 
cocci. I  personally  have  observed"  that  such  cases  have 
a  convalescence  prolonged  much  beyond  the  ordinary 
course  seen  in  patients  infected  with  either  separately. 

THE  INFLUENCE  OF  THE  ANATOMY  ON  THE  COURSE. 

A  general  rule  which  the  anatomy  emphasizes  is  that 
from  any  given  point  the  superficial  lymphatics  pursue 
the  shortest  course  to  the  dorsum.  An  exception  is 
made  of  the  centre  of  the  palm,  from  which,  as  has 
been  shown,  an  infection  would  tend  to  go  down  to 
the  superficial  palmar  arch.  These  are  rare,  however. 
The  general  rule  of  the  dorsal  extension  explains  the 
frequency  of  great  edema  on  the  back  of  the  hand  in 
all  cases.  As  specific  examples  of  the  importance  of 
this  observation,  those  infections  arising  at  the  distal 
part  of  the  palm  should  be  noted.  Here  the  lymphatics 
first  go  distally,  then  pass  around  the  web  and  on  to 
the  dorsum,  at  which  site  the  swelling  and  redness  are 
seen,  giving  rise  to  the  assumption  on  the  part  of  the 
thoughtless  that  the  infection  is  primarily  there.  This 
is  then  followed  by  unnecessary  and  harmful  incisions. 
A  little  care  would  have  shown  that  the  starting-point 
was  a  slight  fissure  in  the  callus  on  the  flexor  surface, 
and  that  the  dorsal  redness  was  lymphatic  in  nature, 
accompanied  by  an  inflammatory  edema  which  would 
be  harmed  rather  than  helped  by  an  incision.  The 
same  is  true  of  infections  upon  the  ulnar  and  radial 
sides  of  the  palm.  Where  there  is  localized  redness  on 
the  dorsum  of  the  hand  we  less  often  see  the  dorsal 


THE  INFLUENCE  OF  ANATOMY  ON   THE  COURSE     327 

lines  of  redness  running  up  the  arm.  These  are  gener- 
ally the  accompaniment  of  an  absence  of  local  reaction. 
Along  the  course  of  the  lymph  vessels,  particularly 
on  the  dorsum  of  the  hand,  will  be  found  areas  of 
redness  and  edema  about  twice  the  width  of  the  red- 
ness accompanying  the  vessels,  appearing  as  if  the 

FIG.  115 


Showing  lymphatics  in  the  skin  and  around  the  nail  in  a  child,  aged  four 
years.    (After  Sappey.) 

infection  were  localizing  there  or  as  if  small  abscesses 
were  forming.  These  may  be  incised  under  that 
assumption.  It  is  doubtless  true  that  in  the  semi- 
acute  cases,  or  those  going  on  to  abscess  formation,  the 
localizing  processes  may  start  from  these  foci,  but  great 
care  should  be  exercised  before  making  this  deduction, 


328  LYMPHANGITIS 

since  these  are  but  the  evidences  of  the  lacunae  men- 
tioned in  the  anatomical  discussion,  and  generally  sub- 
side at  the  same  time  the  inflammation  disappears  from 
the  vessel  proper. 

Attention  should  also  be  drawn  to  the  normal  course 
of  the  vessels,  and  it  should  be  emphasized  that  lym- 
phatic extension  from  the  little  and  ring  finger  takes 
place  through  the  epitrochlear  glands,  then  to  the 
axillary,  while  infections  beginning  in  the  thumb  and 
forefinger  go  to  the  axillary  glands  without  the  inter- 
position of  the  epitrochlear;  hence  systemic  infection  is 
more  easily  engendered,  and,  moreover,  if  the  observer 
were  searching  for  glandular  enlargement  he  would  not 
expect  to  find  it  at  the  elbow  in  these  cases.  Infec- 
tions beginning  in  the  middle  finger .  are  of  special 
interest  in  that  either  the  axilla  or  the  epitrochlear 
glands  may  be  first  involved,  and  in  some  cases  neither 
of  these  areas  may  receive  the  lymphatic  vessels,  since 
they  may  pass  up  over  the  clavicle  and  into  the  sub- 
clavian  glands  and  thus  directly  into  the  circulation. 
The  clinical  importance  of  this  lies  in  the  fact  that 
these  infections  may  reach  the  circulation  very  early 
and  because  of  the  rapidity  of  involvement  lead  to 
severe  and  even  fatal  systemic  infection.  I  have  had 
one  case  that  lends  support  to  this  assmption.  There- 
fore, one  would  look  with  great  anxiety  upon  severe 
infections  arising  from  the  middle  and  index  fingers. 

In  some  of  the  patients  the  lymphatic  infection 
rapidly  spreads  from  the  lymphatic  vessel  and  extends 
over  the  entire  dorsum  of  the  hand  and  forearm  with 
the  appearance  of  an  erysipelas  without  the  raised 
border.  The  swelling  is  considerable,  the  skin  takes 
on  a  board-like  hardness,  and  vesicles  may  appear  on 
the  surface.  This  may  subside  without  further  trouble, 
but  very  often  subcutaneous  tissue  soon  becomes 
involved  and  diffuse  abscess  formation  takes  place. 


THE  INFLUENCE  OF  ANATOMY  ON   THE  COURSE    329 

These  are  ordinarily  virulent  cases  and  should  be  care- 
fully watched  and  the  abscesses  opened. 

There  is  an  intimate  relation  between  the  lymphatics 
of  the  distal  extremity  and  the  tendon  sheaths.  Of 
this  I  have  no  anatomical  proof,  but  such  clinical 
evidence  that  there  can  be  no  doubt  of  the  association. 

FIG.  116 


Lymphatics  about  one  of  the  palmar  flexion  creases.     (After  Sappey.) 

It  has  been  my  experience  frequently  to  meet  with 
cases  in  patients  with  pin  pricks,  especially  of  the  distal 
phalanx,  which  lead  to  a  typical  lymphangitis  with  a 
red  line  running  up  the  arm,  and  after  a  couple  of  days 
these  would  show  the  typical  evidences  of  tendon- 
sheath  infection  of  the  finger  involved.  The  distal 


330  .  LYMPHANGITIS 

phalanx  itself,  the  site  of  the  primary  injury,  would 
show  little  or  no  serious  consequences.  This  will  be 
discussed  more  fully  under  symptomatology. 

If  the  deep  lymphatics  are  involved,  the  course 
naturally  follows  the  course  of  the  veins,  as  has  been 
pointed  out  above.  If  localized  abscesses  develop,  they 
appear  along  the  line  of  these  vessels.  If  it  be  the 
interosseous,  the  abscesses  will  naturally  lie  under 
the  flexor  profundus,  thus  occupying  the  site  I  have 
already  pointed  out  as  that  in  which  the  deep  abscesses 
spreading  from  the  tendon  sheaths  are  always  found. 
In  these  cases  doubtless  the  tendon  sheaths  would  be 
involved  early,  and  then  we  would  have  a  typical 
tendon-sheath  infection. 

If  the  lymphatic  vessels  along  the  radial  and  ulnar 
vessels  are  the  source,  the  abscess  will  naturally  lie 
along  these  vessels.  It  has  not  been  my  experience  to 
meet  with  any  such  cases,  and  I  am  inclined  to  believe 
that  their  occurrence  is  uncommon.  I  have  seen 
abscesses  along  the  brachial  vessels,  however.  In  one 
case  it  developed  as  an  extension  from  a  deep  infection 
of  the  forearm,  and  in  another  as  the  sequel  of  a  typical 
superficial  lymphangitis  of  the  forearm.  It  seemed 
to  me  reasonable  in  this  latter  case  to  ascribe  its 
development  to  suppuration  in  a  lymphatic  gland  lying 
in  juxtaposition  to  the  vessel,  since  we  know  that,  while 
these  glands  ordinarily  lie  at  the  elbow  and  axilla, 
they  may  occur  at  any  part  of  the  lymphatic  stream. 
From  the  very  nature  of  the  cases  we  would  expect 
deep  lymphatic  abscesses  to  be  uncommon. 

SPOROTRICHOSIS. 

Certain  cases  in  which  nodules  develop  along  the 
lines  of  the  lymphatics,  giving  rise  to  small  abscess 
formation,  may  cause  confusion  in  that  it  is  possible 


LYMPHATIC  ABSCESSES  331 

for  us  to  have  in  traumatic  injuries  of  the  hand  an 
infection  by  sporotrichosis.  Practically  all  of  these 
infections  follow  open  wounds.  It  is  first  described 
by  Schenck. 

The  disease  seems  fairly  prevalent  in  rural  districts. 
It  is  possible  that  some  of  the  cases  have  been  diag- 
nosticated as  tuberculous  lymphangitis.  The  organism 
consists  of  a  branching  septate,  coarse  mycelium  from 
which  ovoid  bodies  develop  by  budding,  either  from 
lateral  or  terminal  filaments  or  from  the  sides  of  the 
threads.  These  ovoid  bodies  are  spores. 

The  condition  is  characterized  by  the  history  of  a 
traumatic  injury,  and  is  accompanied  by  the  develop- 
ment of  one  or  more  sharply  circumscribed,  painless 
or  subcutaneous  abscesses  along  the  course  of  the 
lymphatic.  Inflammatory  manifestations  are  generally 
absent.  The  course  is  extremely  chronic,  lasting  for 
a  number  of  weeks. 

The  treatment  consists  in  thoroughly  opening  the 
abscesses,  cleansing  them,  and  giving  large  doses  of 
potassium  iodide  internally. 


RELATIONS  OF  LYMPHATIC  ABSCESSES  STUDIED  BY 
EXPERIMENTAL  INJECTIONS. 

In  order  to  study  the  subject,  attempts  were  made 
to  inject  masses  from  given  sites  along  the  vessels  in 
cadaver  hands.  The  results  did  not  add  much  to  our 
knowledge,  but  I  will  summarize  them  here. 

REPORT  OF  INJECTIONS  OF  FOREARM  NEAR  THE 
RADIAL  AND  ULNAR  VESSELS. — Experiment  i. — Can- 
nula  passed  through  small  incision  superficial  to.  the 
radial  vessels  just  above  the  wrist.  The  mass  was 
injected  with  considerable  force,  and  on  examination 
a  superficial  area  three  inches  in  length  and  one  inch 
in  diameter  was  found  filled  with  the  injected  mass. 


332  LYMPHANGITIS 

(NOTE. — It  is  extremely  difficult  in  injecting  the 
cannula  to  know  just  exactly  the  position  it  occupies.) 

Experiment  2. — Injected  posteriorly,  i.  e.,  dorsal  to 
the  radial  vessels.  The  mass  spread  upward,  and  in  the 
section  was  found  to  lie  on  the  radial  side  of  the  flexor 
longus  pollicis,  tearing  the  muscle  to  a  great  extent 
up  to  its  origin.  The  mass  had  extended  to  the  ulnar 
side  of  this  vessel,  a  small  part  of  it  lying  on  the  radial 
side  between  the  bodies  of  the  flexor  profundus  digi- 
torum  and  flexor  sublimis  digitorum.  The  greater 
portion  had  passed  underneath  the  flexor  profundus 
digitorum  and  filled  up  the  area  between  this  muscle 
and  the  bones  with  the  interosseous  membrane.  It 
had  extended  to  the  ulnar  side,  lying  in  juxtaposition 
to  the  flexor  carpi  ulnaris,  and  at  its  distal  end  came  to 
lie  near  the  surface,  i.  e.,  near  the  ulnar  vessels.  It 
had  extended  distally  between  the  tendons  of  the  flexor 
profundus  digitorum  and  the  pronator  quadratus.  It 
did  not  pass  into  the  hand.  It  has  extended  en  masse 
approximately  to  about  three  inches  below  the  elbow- 
joint,  and  a  small  prolongation  or  isthmus  extended 
along  the  median  nerve  above  the  elbow-joint  for  three 
or  four  inches  into  the  arm,  still  lying  close  to  the 
median  nerve  and  consequently  near  the  brachial 
vessels  and  accompanying  nerves.  (NOTE. — Out  of  six 
injections  more  or  less  satisfactory,  this  extension  oc- 
curred in  two  cases,  suggesting  why  it  is  that  in  deep 
infections  of  the  forearm,  loss  of  function  of  the  muscles 
is  so  uncommon,  since  both  the  blood  supply  and  the 
nerve  supply  are  impaired.) 

Experiment  3.- — Results  practically  the  same  as 
Experiment  2. 

Experiment  4. — Results  practically  the  same  as 
Experiment  I. 

Experiment  5. — Mass  lay  to  the  radial  side  of  the 
arm  above  the  flexor  longus  pollicis  and  to  the  radial 
side  of  the  flexor  profundus  digitorum. 


THE  PATHOLOGY  OF  LYMPHANGITIS  333 

GENERAL  CONCLUSIONS  IN  THIS  SERIES  OF  EXPERI- 
MENTS UPON  THE  RADIAL  VESSELS. — We  have  demon- 
strated that  if  an  abscess  should  develop  along  the 
course  of  the  lymphatic  vessels,  lying  in  juxtaposition 
to  the  radial  artery,  it  may  be  a  superficial  abscess 
which  would  point  on  the  radial  side  of  the  arm.  If 
it  follows  the  vessels  farther  it  may  spread  to  the  deep 
tissues  of  the  arm.  In  other  words,  it  may  produce 
the  same  result  as  an  extension  along  the  interosseous 
vessels  or  a  rupture  from  the  ulnar  or  the  radial  syno- 
vial  sheaths.  It  may  extend  to  the  ulnar  side  and  lie 
immediately  under  the  skin. 

EXPERIMENTS  BY  INJECTION  ALONG  THE  ULNAR 
ARTERY. — As  in  the  injections  along  the  radial  artery, 
these  experiments  are  more  or  less  unsatisfactory  owing 
to  the  fact  that  there  was  always  considerable  doubt 
as  to  the  exact  position  the  tip  of  the  cannula  occupied, 
although  the  intention  was  to  inject  as  close  to  the 
ulnar  artery  as  possible,  i.  e.,  to  simulate  the  origin 
of  a  large  abscess  coming  from  the  lymphatics  and 
lying  in  juxtaposition  to  this  vessel. 

In  this  series  five  injections  were  made  at  various 
sites,  and  demonstrated  the  tendency  of  such  accumula- 
tions to  come  to  the  surface  on  the  ulnar  side  early  in 
the  course.  If  the  injection  was  persisted  in,  the  area 
of  the  forearm  involved  was  first  that  between  the 
flexor  carpi  ulnaris  and  the  flexor  prof undus  digitorum ; 
then  between  the  superficial  and  deep  flexors,  and  then 
the  area  between  the  deep  flexor  and  the  bone,  i.  e., 
the  typical  deep  abscess  of  the  forearm. 

THE  PATHOLOGY  OF  LYMPHANGITIS. 

The  pathology  of  these  cases  concern's  itself  particu- 
larly with  the  changes  in  the  lymph  vessels  and  glands, 
and  need  not  be  discussed  in  completeness,  since  the 
general  facts  are  well  known.  A  picture  of  the  condi- 
tion found  in  a  typical  case  will  be  as  follows: 


334  LYMPHANGITIS 

The  local  changes  at  the  site  of  injury  may  be  so  in- 
significant as  to  escape  notice.  The  local  reaction,  even 
in  a  case  that  threatens  lethal  issue,  may  be  nothing 
more  than  a  slight  redness  indicative  of  a  hyperemia. 
There  is  no  hardness  suggestive  of  the  outpouring  of 
the  protective  leukocytes  with  the  coagulation  of  the 
lymph  and  blood  elements  about  a  site  of  injury  and 
infection,  as  is  seen  in  the  localized  staphylococcus 
infection,  although  great  pain  may  be  present.  This 
is  particularly  seen  in  the  distal  phalanx,  where  the 
differential  diagnosis  between  this  condition  and  a 
beginning  felon  must  be  made. 

The  lymphatic  vessels  show  grossly  by  their  redness 
the  hyperemia  surrounding  them,  and  a  microscopic 
examination  shows  the  destruction  of  the  endothelium, 
suggesting  a  virulent  poison  or  great  activity  in  over- 
coming the  bacteria.  Adami  has  emphasized  the  im- 
portant part  the  endothelial  cells  play  in  inflammations, 
in  that  they  may  act  as  phagocytes  and  may  undergo 
changes  to  giant  cells  or  other  forms  more  fitted  to 
combat  the  process.  A  cross-section  will  show  these 
changes,  and  in  addition  may  show  the  vessels  filled 
by  a  thrombus  made  up  of  cells  and  bacteria,  and  in 
those  cases  where  the  thrombus  lies  close  to  the  wall 
the  bacteria  may  be  seen  in  that  also.  If  the  vessel 
is  injured  or  cut,  the  bacteria  spread  beyond  the  wall, 
but  in  the  ordinary  simple  case  they  will  be  found 
confined  to  the  wall  and  the  lumen.  The  bacteria  do 
not  seem  to  be  in  the  leukocytes  to  any  great  extent, 
but  they  are  so  mixed  together  in  the  thrombus  as  to 
leave  some  doubt  in  my  mind  on  this  point.  At  some 
points  I  have  found  the  thrombus  entirely  free  from 
bacteria,  in  which  case  it  may  be  reasoned  that  the 
toxin  has  produced  the  thrombus  in  advance  of  bac- 
terial extension.  In  some  instances,  in  spite  of  the 
changes  in  the  lumen,  the  vessel  wall  showed  little 


RESUME  335 

change.  The  endothelium  was  not  changed.  There 
were  no  endothelium  giant  cells.  The  connective  tissue 
about  showed  the  evidences  of  inflammation  with 
moderate  round-celled  infiltration,  although  this  did 
not  extend  far  into  the  adjacent  areas.  The  capillaries 
were  engorged  with  blood  for  some  distance,  and  the 
connective-tissue  fibers  were  separated  by  the  serous 
exudate.  If  the  inflammation  is  a  chronic  one,  all  of 
the  changes  incident  to  such  infection  are  seen.  If 
the  vessel  is  cut,  there  is  a  rapid  extension  to  the  sur- 
rounding tissue,  which  macroscopically  takes  on  the 
appearance  of  an  erysipelas  and  pathologically  shows 
the  inflammatory  changes  associated  with  it.  About 
the  lacunae  the  changes  I  have  just  described  are  most 
marked,  a  much  wider  area  about  them  being  involved. 

The  lymph  glands  show  nothing  different  from  the 
ordinary  picture  seen  in  varying  inflammations  of  their 
structure.  Systemically  in  severe  cases  marked  changes 
in  the  blood  and  various  organs  are  found  which  will 
be  discussed  when  speaking  of  the  fatal  cases. 

In  the  severe  cases  locally  we  may  find  that  the 
subcutaneous  tissue  and  even  the  skin  may  become 
gangrenous.  Of  course,  the  former  is  most  common. 
Here  the  abscess  will  form,  and  when  opened  large 
sloughs  of  connective  tissue  may  be  removed  from 
which  the  streptococcus  may  be  secured  in  pure 
culture. 

RESUME. 

The  source  of  lymphangitis  is  frequently  an  injury 
so  slight  as  not  to  be  recognized  or  remembered  by  the 
patient.  It  is  probable  that  in  the  majority  of  cases 
the  organism  at  fault  is  the  streptococcus,  but  various 
pathological  organisms  may  be  found. 

Gonorrheal  lymphangitis  occurs  as  a  result  of 
systemic  infection. 

While  hemolysis  is  often  a  marked  accompaniment 


336  LYMPHANGITIS 

of  streptococcous  lymphangitis,  it  is  not  necessarily 
present.  In  very  severe  types  of  infection  the  effect 
of  symbiosis  is  not  definitely  determined. 

The  lymphatics  pursue  the  shortest  course  to  the 
back  of  the  hand,  consequently  infection  at  the  distal 
portion  of  the  palm  will  spread  around  the  web  into 
the  dorsum.  In  case  of  local  infection  in  the  palm  the 
swelling  of  the  dorsum,  due  to  edema,  may  be  very 
great,  even  greater  than  on  the  palm.  Care  should  be 
exercised  not  to  incise  on  the  dorsum  but  in  the  palm 
in  such  cases. 

Small  areas  along  the  inflamed  lymphatic,  the  size 
of  a  small  pea,  which  appear  red  and  swollen,  indicate 
lacunae  in  the  course  of  the  vessels  and  are  not  an 
evidence  of  localized  infection  and  should  not  be  incised. 

The  little  finger  and  ring  finger  drain  into  the 
epitrochlear  glands  and  then  to  the  axillary.  A  small 
percentage  of  infections  beginning  in  the  middle  finger 
pass  directly  up  over  the  clavicle  and  into  the  sub- 
clavian  glands  without  passing  through  either  the 
epitrochlear  or  axillary  glands.  The  thumb  and  index 
finger  drain  into  the  axillary  glands. 

Deep  lymphatic  abscesses  are  uncommon. 

Sporotrichosis  may  be  seen  and  should  be  differ- 
entiated from  tuberculous  and  other  chronic  processes. 

Abscesses  following  the  deep  lymphatics  will  lie 
along  the  vessels.  If  one  develops  along  the  radial 
artery  it  will  appear  on  the  radial  side  of  the  arm  in 
the  lower  third.  If  the  abscess  extends  upward,  it  will 
enter  the  deeper  portion  of  the  arm  and  will  become 
a  submuscular  abscess.  If  along  the  ulnar  vessel  the 
pus  will  readily  come  to  the  surface  between  the  flexor 
carpi  ulnaris  and  the  flexor  sublimis  digitorum. 

The  pathological  change  in  the  lymphatic  vessels 
is  that  observed  in  any  inflammation. 

In  an  exceptionally  severe  case,  marked  sloughing 
of  the  entire  subcutaneous  tissue  may  occur. 


CHAPTER  XXI. 
SYMPTOMS  AND  SIGNS  OF  LYMPHANGITIS. 

SYMPTOMS  AND  SIGNS  IN  GENERAL. 

A  PATIENT  with  a  lymphangitis  ordinarily  gives  a 
history  of  a  slight  abrasion  or  pin  prick,  which  had  been 
considered  of  no  importance.  Frequently  no  history 
of  injury  can  be  secured.  The  patient  has  noticed  a 
slight  malaise  or  chilly  sensations,  possibly  a  severe 
chill  may  be  noted.  There  may  be  no  local  pain  in  the 
hand  or  arm  and  no  swelling.  Generally,  however, 
there  is  slight  swelling  accompanied  by  a  dull  pain,  and 
at  times  the  edema  on  the  dorsum  may  become  marked 
and  the  pain  very  severe.  The  symptoms  and  signs 
bring  the  patient  to  the  physician,  who  finds  in  addition 
to  the  local  condition  a  red  line  running  up  the  forearm 
and  arm  corresponding  to  the  anatomical  distribution 
of  the  lymphatic  vessels  draining  the  area  of  primary 
infection.  There  may  or  may  not  be  tenderness  or 
swelling  in  the  region  of  the  epitrochlear  or  axillary 
glands.  Generally,  however,  after  the  infection  has 
lasted  twenty-four  hours  some  tenderness  and  swelling 
are  found.  The  arm  as  a  whole  may  show  some  slight 
swelling,  although  this  is  generally  absent. 

The  degree  of  systemic  involvement  varies  in  the 
widest  limits.  In  some  cases,  even  early  in  the  course, 
the  patient  will  present  the  evidences  of  severe  toxemia 
with  a  chill  and  high  or  low  temperature,  headache, 
anorexia,  and  prostration.  In  a  majority  of  cases, 
however,  these  severe  symptoms  are  delayed  two  or 
three  days,  even  though  there  may  be  a  severe  onset 
with  a  chill,  temperature,  and  headache. 

22 


338      SYMPTOMS  AND  SIGNS  OF  LYMPHANGITIS 

TYPES. 

Four   types  may  be  seen. 

TYPE  I.  SIMPLE  ACUTE  LYMPHANGITIS. — If  the 
process  subsides,  the  physician  may  be  surprised  at 
the  rapid  disappearance  of  all  evidences  of  the  infec- 
tion both  systemic  and  local.  All  objective  evidences 
may  entirely  disappear  in  from  twenty-four  to  forty- 
eight  hours.  The  red  line  of  lymphatic  inflammation 
may  disappear  over  night  with  slight  tenderness  over 
the  gland  area  persisting  for  a  few  hours  longer. 

TYPE  II.  ACUTE  LYMPHANGITIS  WITH  MINOR  LOCAL 
COMPLICATIONS. — In  a  second  group  the  symptoms 
may  subside  more  slowly  and  end  in  a  delayed  reso- 
lution or  even  abscess  at  the  site  of  inoculation  or  in 
the  gland  area  accompanied  by  mild  systemic  symp- 
toms. 

TYPE  III.  ACUTE  LYMPHANGITIS  WITH  SERIOUS 
LOCAL  COMPLICATIONS. — In  a  third  group  of  cases 
complications  arise  ending  in  tenosynovitis  or  sub- 
cutaneous abscesses.  These  cases  are  accompanied 
by  severe  pain  early  in  the  course  and  symptoms 
more  or  less  grave  which  arouse  the  anxiety  of  the 
physician,  first,  as  to  the  possibility  of  early  death 
from  systemic  infection,  and  later,  on  account  of  the 
toxemia  associated  with  the  local  process,  which  heals 
slowly  and  threatens  the  life  of  the  patient  or  raises 
the  question  as  to  the  necessity  for  amputation. 

TYPE  IV.  ACUTE  LYMPHANGITIS  WITH  SYSTEMIC 
INVOLVEMENT. — In  a  fourth  group  the  process  may 
give  rise  at  once  to  most  alarming  systemic  symptoms 
and  with  or  without  local  difficulty  end  fatally  in  a 
few  days. 

The  first  and  second  groups  are  easily  classified  and 
understood. 


LYMPHANGITIS  WITH  LOCAL  COMPLICATIONS    339 


ACUTE  LYMPHANGITIS  WITH   SERIOUS   LOCAL 
COMPLICATIONS. 

The  third  type  may  be  a  constant  source  of  anxiety, 
and  the  surgeon  is  often  in  doubt  as  to  the  ability  of 
the  patient's  resistance  to  cope  with  the  infection,  and 
he  is  constantly  questioning  the  correctness  ot  his 
diagnosis  as  to  the  position  of  pockets  of  pus  and 
the  adequacy  of  his  treatment.  It  may  clear  up  the 
picture  somewhat  to  illustrate  this  by  one  or  two 
examples. 

CASE  XVIII. — A  patient,  Mr.  L.  W.,  was  seen  by 
me  on  the  second  day  of  his  infection.  He  had  injured 
the  forefinger  of  his  left  hand  with  a  piece  of  fine,  rusty 
wire  which  had  penetrated  the  distal  phalanx  upon  the 
volar  surface.  He  was  complaining  of  severe  pain  in 
the  entire  finger,  but  most  marked  in  the  distal  phalanx. 
An  examination  showed  that  the  entire  finger  partook 
of  a  pinkish  hue,  and  was  somewhat  swollen  throughout. 
The  distal  phalanx,  while  the  most  painful  and  tender, 
lacked  the  induration  characteristic  of  localized  infection. 
A  red  line  ran  up  the  back  of  the  hand  and  forearm  and 
could  be  traced  to  the  axilla,  where  slightly  tender  glands 
could  be  palpated.  He  was  profoundly  ill,  with  a  tem- 
perature of  104°  to  1 06°. 

The  proper  procedure  was  considered  to  be  that  of 
applying  a  hot  boric  solution  dressing,  rest  both  local 
and  general,  eliminatives,  and  sedatives.  The  ques- 
tion immediately  arises  as  to  the  advisability  of 
incising  the  distal  phalanx.  It  seemed  to  me  that 
lacking  the  induration,  suggestive  of  localized  pus, 
the  incision  would  do  little  good,  and  might  open  new 
avenues  for  absorption.  There  could  have  been  no 
question  as  to  making  incisions  at  other  points.  Upon 
the  third  day  our  conservatism  was  rewarded  by 
seeing  the  pain  disappear  from  the  distal  phalanx 


340      SYMPTOMS  AND  SIGNS  OF  LYMPHANGITIS 

as  well  as  the  red  line  of  lymphatic  involvement  in 
the  arm.  The  patient  now  located  and  limited  the 
tenderness  to  an  area  over  the  tendon  sheath  of  the 
index  finger.  There  was  no  increase  of  the  swell- 
ing of  the  distal  phalanx,  although  the  finger  as  a 
whole  had  taken  on  the  full  appearance  characteristic 
of  distention  of  the  sheath  with  pus.  The  tendon 
sheath  was  opened  and  the  pus  evacuated,  following 
which  the  patient  ultimately  recovered  with  a  pre- 
servation of  the  finger.  It  should  be  noted  that  no 
incision  was  made  into  the  distal  phalanx,  although 
that  was  the  site  of  the  original  pain  and  tenderness. 
Moreover,  upon  the  second  day  it  was  certainly 
impossible  to  make  the  diagnosis  of  tenosynovitis. 

CASE  XIX. — Mr.  Geo.  W.  applied  to  the  dispensary 
of  the  Post-Graduate  Hospital  with  a  history  of  having 
had  a  small  cut  upon  the  ulnar  side  of  the  palm.  Sud- 
denly, after  three  days,  he  suffered  from  a  chill  and  felt 
feverish.  The  hand  began  to  swell,  especially  upon  the 
dorsum.  Upon  examination  the  remains  of  a  small 
cut  could  be  seen  upon  the  palm,  but  there  was  no  evi- 
dence of  inflammation  about  it.  No  localized  tenderness 
or  swelling.  The  dorsum  of  the  hand,  especially  upon  the 
ulnar  side,  was  greatly  swollen  and  reddish.  The  skin 
of  the  entire  dorsum  was  red.  There  was  no  subcutaneous 
induration,  and  the  skin  itself,  while  red,  did  not  have 
the  brawny  induration  found  in  erysipelas.  A  red  line 
of  lymphatic  involvement  ran  up  on  the  dorsum  of  the 
forearm,  and  could  be  traced  to  the  epitrochlear  region 
and  then  along  the  inner  side  of  the  arm  to  the  axilla. 
Tender  glands  could  be  palpated  in  both  regions.  Tem- 
perature, 103°;  pulse,  100. 

The  question  arose  whether  or  not  an  incision 
should  be  made  over  the  tender  swollen  dorsum.  It 
was  reasoned  that  this  was  not  indicated,  since 
there  was  no  evidence  of  a  localized  abscess  here  or 
of  a  diffuse  phlegmon,  which  at  times  accompanies 


PHLEGMONOUS  LYMPHANGITIS  341 

erysipelatous  infection  in  this  region.  Conservative 
treatment  was  therefore  instituted  with  a  rapid 
cessation  of  all  symptoms  in  the  hand  and  lymphatic 
vessels.  However,  the  tenderness  gradually  increased 
in  the  epitrochlear  region,  and  a  redness  which  had 
not  been  present  before  now  appeared.  At  the  end 
of  seven  days  a  suppuration  which  had  had  its  origin 
in  the  gland  here  was  diagnosticated.  Drainage  was 
instituted,  with  complete  recovery  in  a  short  time. 

PHLEGMONOUS  LYMPHANGITIS. — One  of  the  most 
serious  types  is  that  in  which  the  infection  seems 
to  involve  the  skin  of  the  back  of  the  hand  and  fore- 
arm like  an  erysipelas.  The  toxemia  is  great,  the 
forearm  greatly  swollen,  and  the  board-like  skin 
shows  small  blebs  or  blisters  upon  its  surface.  The 
bacteria  soon  invade  the  subcutaneous  tissue  and 
lead  to  a  destruction  of  areas  of  the  subcutaneous 
tissue  en  masse,  thus  leaving  the  infected  skin  without 
proper  blood  supply.  Consequently,  large  pockets 
filled  with  pus  and  seminecrotic  tissue  underlie  the 
skin  of  the  dorsum,  which  itself  soon  becomes  gan- 
grenous in  spots.  Meanwhile,  the  patient  is  suffering 
from  a  severe  toxemia  or  sepsis.  The  superficial 
veins  may  become  thrombosed  and  threaten  death 
by  acting  as  the  source  of  infection,  even  though  the 
lymphatic  absorption  may  have  ceased.  The  greatest 
care  should  be  exercised  in  differentiating  this  type 
from  the  swollen,  reddened,  edematous  form  seen  in 
ordinary  lymphangitis,  in  which  there  is  no  induration 
either  of  the  skin  or  subcutaneous  tissue. 

Examples  of  these  types  could  be  multiplied  many 
times  in  my  experience.  The  early  signs  and  symp- 
toms very  commonly  point  to  an  entirely  different 
area  as  the  probable  site  of  abscesses  than  the  one  in 
which  it  ultimately  develops,  and  I  wish  to  emphasize, 
therefore,  that  the  diagnosis  of  the  accumulation  of 


342      SYMPTOMS  AND  SIGNS  OF  LYMPHANGITIS 

pus  should  be  made  only  upon  positive  signs.  After 
once  localizing,  the  abscesses  follow  the  definite  lines 
laid  down  in  the  chapters  upon  tenosynovitis  and 
fascial  space  infection. 

THE  FREQUENCY  OF  LOCALIZATION  IN  LYMPHATIC 
INFECTION. — The  frequency  with  which  localization 
takes  place  in  lymphangitis  is  hard  to  state  accu- 
rately. In  my  experience  10  to  15  per  cent,  of  the  cases 
would  probably  be  nearly  correct,  and  if  anything  it 
would  be  less  rather  than  more  than  that.  The  sites 
of  such  involvement  are  ordinarily  the  tendon  sheaths 
of  the  respective  finger,  the  dorsum  of  the  hand,  the 
dorsum  of  the  forearm,  the  axilla,  and  the  epitroch- 
lear  region.  Secondary  to  tendon-sheath  infections 
and  deep  infections  of  the  hand,  it  is  common  to  find 
a  subcutaneous  accumulation  of  pus  of  lymphatic 
origin  on  the  flexor  surface  of  the  wrist.  From  these 
observations  it  is  very  evident  that  a  great  majority 
of  the  cases  of  lymphangitis  subside  without  second- 
ary abscesses  unless  they  are  engendered  by  ill-advised 
incisions. 

ACUTE  LYMPHANGITIS  WITH   SYSTEMIC  INVOLVEMENT. 

In  our  classification  we  have  included  in  this  group 
those  severe  infections  which  through  systemic  absorp- 
tion or  infection  threaten  or  destroy  the  life  of  the 
individual.  They  may  arise  from  any  source  or  in 
any  individual.  They  are  more  likely  to  occur  in 
individuals  over  thirty-five  years  of  age,  and,  if  fatal, 
within  a  short  time  are  more  inclined  to  follow  infec- 
tions of  the  thumb,  index  or  middle  finger.  The  little 
finger  is  the  origin  of  many  fatal  cases,  but  here  the 
lethal  issue  is  often  due  to  infection  through  involve- 
ment of  the  tendon  sheaths  with  improper  drainage. 
In  other  words,  death  is  the  outcome  of  two  types  of 


LYMPHANGITIS  WITH  SYSTEMIC  INVOLVEMENT    343 

infections:  (i)  An  acute  type  without  localization 
in  the  hand,  and  (2)  a  severe  type  with  localization, 
subsequent  toxemia  from  inadequate  drainage,  and 
the  inability  of  the  patient's  system  to  wall  off  the 
infection,  ending  in  death  from  exhaustion  and  sepsis. 
These  types  will  be  discussed  when  dealing  with 
systemic  infection,  and  we  shall  mention  them  only 
briefly  here  for  the  sake  of  completeness.  The  onset 
is  generally  brusque.  The  patient  suffers  a  chill, 
followed  by  a  high  temperature,  which  later  becomes 
lower  as  the  toxemia  increases.  There  is  little  local 
reaction  along  the  line  of  the  lymphatic  or  other  gland- 
ular region.  The  prostration  is  profound,  the  head- 
ache severe.  The  face  becomes  pinched,  the  eyes 
roving,  the  pulse  running,  and  the  patient  is  restless 
and  cannot  sleep.  The  prostration  becomes  greater, 
the  pulse  more  running,  the  temperature  normal, 
subnormal,  or  high,  the  skin  clammy  and  the  nose 
cold;  in  other  words,  the  typical  picture  of  a  virulent 
toxemia.  Meanwhile  the  physician  looks  on  helplessly, 
since  there  is  no  localization  which  he  may  attack. 

DEEP  LYMPHANGITIS. — The  diagnosis  of  deep  lym- 
phangitis must  often  remain  in  doubt,  since  it  is 
generally  associated  with  a  superficial  inflammation, 
at  times  showing  red  lymphatic  lines,  but  generally 
appearing  as  of  the  erysipelatous  type.  The  whole 
arm  and  forearm  are  swollen  as  if  the  extremity  were 
a  sac  and  the  whole  filled  with  fluid.  It  will  be  noted 
that  this  is  different  from  the  appearance  in  superficial 
lymphangitis,  in  which  the  back  of  the  forearm  is 
swollen  out  of  proportion  to  the  front.  There  is  ten- 
derness early  throughout,  but  most  marked  on  the 
dorsum,  where  the  superficial  lymphatics  are  acutely 
inflamed.  The  patient  is  generally  profoundly  ill 
with  all  the  evidences  of  toxemia.  In  no  case  that  I 
have  had  has  there  been  any  localization  of  pus  about 


344      SYMPTOMS  AND  SIGNS  OF  LYMPHANGITIS 

the  deeper  portion  of  the  arm.  In  one  patient  an 
abscess  localized  itself  along  the  radial  artery  about 
two  inches  above  the  wrist.  This  was  subsequently 
drained,  with  recovery  of  the  patient.  I  have  not 
seen  any  cases  with  abscesses  under  the  flexor  pro- 
fundus  tendons  which  could  not  be  explained  on  the 
assumption  of  an  extension  from  a  ruptured  tendon 
sheath,  although  it  is  certain  they  are  possible. 

A  fatal  case  of  deep  lymphangitis  came  under  my 
notice  a  short  time  ago,  in  which  the  patient  made 
a  primary  recovery,  but  died  after  four  weeks  from  a 
pneumonia,  probably  directly  dependent  upon  the 
primary  infection.  Indeed,  these  serious  'cases  of 
infection  frequently  come  to  a  fatal  issue  because 
of  some  intercurrent  complication,  and  such  should 
always  be  looked  for  and  guarded  against.  A  brief 
resume  of  the  case  will  emphasize  the  clinical  picture. 

CASE  XX. — Mr.  J.  R.  D.  (Fig.  117),  an  employee  of 
the  customs  house,  bruised  the  thumb  of  his  left  hand 
in  getting  off  a  street  car.  As  he  expressed  it,  he  thought 
that  he  had  dislocated  the  thumb.  There  was  some 
primary  swelling.  At  the  end  of  the  third  day  there  was 
a  considerable  increase  of  the  swelling,  so  that  the  whole 
thenar  area  was  involved,  and  the  forearm  also  began 
to  increase  in  size.  He  now  consulted  Dr.  J.  J.  Cole, 
with  whom  I  saw  the  patient  in  consultation.  The  swell- 
ing of  the  thenar  area  was  so  great  as  to  suggest  the  bal- 
looning out  seen  in  the  abscess  of  the  thenar  space.  The 
swelling  was  distinctly  an  edema,  however,  there  being 
no  hardness  present.  It  was  treated  by  hot  boric  dressings. 
Within  a  few  hours  the  whole  arm  was  swollen  and  edema- 
tous,  as  much  upon  its  flexor  as  its  dorsal  surface,  although 
the  dorsum  showed  some  redness  which  was  not  present 
on  the  flexor  surface.  Deep  tenderness  could  be  elicited 
on  both  surfaces,  especially  over  the  radial  side.  By 
the  end  of  the  third  day  the  swelling  of  the  arm  had 
subsided  to  a  considerable  extent,  and  the  swelling  of 
the  flexor  surface  of  the  forearm  was  distinctly  less. 


LYMPHANGITIS   WITH  SYSTEMIC  INVOLVEMENT    345 

The  dorsum,  however,  was  still  swollen,  having  the 
appearance  and  giving  the  same  sense  of  hardness  on 
palpation  as  noted  in  erysipelas.  Incisions  made  upon 
the  dorsum  showed  that  the  subcutaneous  connective 
tissue  was  necrotic  en  masse  and  could  be  removed  with 
the  forceps.  The  whole  dorsum  of  the  forearm  was  under- 
mined. Several  incisions  were  made  which  drained 
satisfactorily.  Owing  to  the  large  flaps  of  skin  left  with- 
out blood  supply,  in  which  the  vitality  was  impaired  by 
the  infection,  some  areas  of  this  also  sloughed.  As  the 

FIG.  117 


Photograph  of  the  hand  of  a  patient  with  a  deep  lymphangitis  (phlegmo- 
nous  erysipelas).     (See  Case  XX). 

process  subsided  the  thrombosed  superficial  veins  could 
be  seen  on  the  surface  of  the  deep  fascia.  The  patient 
made  a  rapid  primary  recovery,  so  that  he  left  the  hospital 
at  the  end  of  eight  days.  The  local  process,  however, 
had  not  entirely  healed.  Some  slight  toxemia  was  present, 
from  which  the  patient  was  slowly  recovering,  when  he 
was  suddenly  overtaken  by  a  pneumonia  at  the  end  of 
four  weeks,  and  died  after  three  days.  .  A  culture  taken 
from  a  bleb  which  had  formed  upon  the  skin  showed  a 
staphylococcus  infection.  In  the  subcutaneous  pus,  how- 
ever, a  pure  culture  of  Streptococcus  pyogenes  was  found, 


346      SYMPTOMS  AND  SIGNS  OF  LYMPHANGITIS 

and  I  believe  that  to  have  been  the  source  of  the  infection. 
Unfortunately,  no  postmortem  could  be  secured. 

Incidentally  this  finding  of  the  staphylococcus  under 
the  epidermis  when  the  real  cause  was  a  streptococcus 
emphasizes  the  error  which  is  common  of  mistaking 
the  local  subepidermal  infection  for  the  primary  cause 
when  it  may  be  really  secondary. 

SYSTEMIC  INVOLVEMENT. — As  a  sequence  of  lym- 
phangitis proper  or  associated  with  other  types  of 
infection  of  the  hand,  systemic  involvement  may  be 
seen.  It  occurs  more  frequently  as  the  age  increases. 
While  deaths  may  occur  at  any  age,  by  far  the  greatest 
number  occur  after  forty-five  years,  and  after  fifty 
years  a  severe  infection  of  the  hand  should  be  looked 
upon  with  anxiety.  It  occurs  most  often  associated 
with  a  streptococcus  infection.  In  one  case,  however, 
that  died  under  my  care,  a  staphylococcus  was 
present  in  the  pus  of  the  primary  abscess  (Case  XXI). 
Every  case  showing  evidence  of  septicemia  should  be 
regarded  as  extremely  grave.  Early  in  the  course  it 
may  be  impossible  to  differentiate  a  septicemia  from  a 
toxemia,  since  they  will  present  the  same  picture 
at  the  onset.  The  temperature  is  often  103°  to  106°; 
the  pulse,  120  to  130.  The  dry  tongue  and  skin;  the 
restless,  roving  eyes;  the  constantly  moving  limbs; 
the  thirst;  scanty  urine;  headache;  sleeplessness; 
flushed  cheek;  damp  brow;  and  the  quivering  nostril, 
with  the  history  of  chilly  feelings  or  a  chill,  present 
a  picture  known  to  all,  and  early  may  be  present 
in  either  a  toxemia  or  a  septicemia.  In  a  toxemia, 
however,  all  these  symptoms  should  subside  within 
three  days  if  due  to  a  primary  unopened  lymphangitis 
or  if  it  follows  the  opening  of  an  abscess  or  a  teno- 
synovitis.  If,  instead  of  subsiding,  the  symptoms 
grow  more  severe,  it  is  probable  a  systemic  infection 


LYMPHANGITIS   WITH  SYSTEMIC  INVOLVEMENT    347 

is  present  if  the  local  pockets  of  infection  have  been 
drained.  The  temperature  generally  continues  high 
until  death,  but  may  become  remittent,  showing 
chills  from  time  to  time  or  symptoms  and  signs  inci- 
dent to  complications,  such  as  bronchitis,  pneumonia, 
pleurisy,  lung  abscess,  metastatic  abscesses,  and  teno- 
synovitis,  especially  of  the  extensor  tendon  of  the  great 
toe,  in  my  experience.  The  eye  muscles  may  become 
paralyzed  (Tornier).  Almost  all  cases  die  when  these 
severe  symptoms  develop.  Death  comes  on  with 
the  patient  in  coma  or  delirium.  Should  the  patient 
recover,  the  evidences  of  toxemia  gradually  subside 
and  the  local  wound  begins  to  show  evidences  of  repair. 
The  condition  of  the  local  wound  as  to  repair  is  of 
considerable  prognostic  importance.  When  a  wound 
does  not  heal  as  rapidly  as  it  should  after  opening, 
exceptional  care  as  to  the  systemic  treatment  should 
be  used. 

A  fatal  case  following  a  simple  middle  palmar 
abscess  which  had  been  undiagnosticated  was  referred 
to  me  and  is  worth  reporting,  since  it  illustrates  the 
picture  in  the  septic  cases. 

CASE  XXI. — Mr.  R.  K.,  aged  sixty-five  years,  admitted 
to  the  hospital  January  23,  1909.  Died,  February  I, 
1909. 

The  history  as  recorded  is  very  meager.  He  stated 
that  he  hurt  his  hand  rubbing  meat  and  getting  some 
brine  in  the  scratches  about  a  month  previous  to  entrance, 
December  22,  1908.  Following  this  his  hand  was  swollen 
and  painful.  Several  incisions  had  been  made  on  the 
dorsum.  On  examination  the  right  hand  was  found  to  be 
swollen,  with  the  palm  bulging.  The  fingers  were  slightly 
restricted  in  motion.  Little  restriction  of  motion  at  the 
wrist  and  little  swelling  of  the  forearm.  Systemically 
the  patient  showed  the  results  of  toxemia,  being  pale, 
weak,  and  emaciated,  with  the  hunted  look  characteristic 
of  these  cases.  The  urine  showed  a  specific  gravity  of 


348      SYMPTOMS  AND  SIGNS  OF  LYMPHANGITIS 

1020,  was  scanty  in  amount,  but  contained  no  albumin. 
There  were,  however,  many  hyaline  and  granular  casts, 
both  broad  and  narrow.  A  diagnosis  of  a  middle  palmar 
abscess  was  made,  associated  with  a  toxemia  of  a  high 
grade,  or  asepsis,  and  in  addition  a  nephritis. 

In  view  of  these  findings  and  the  man's  age,  a  poor 
prognosis  was  given.  Operation:  Under  nitrous  oxide 
anesthesia,  a  Bier  constrictor  was  applied  and  about  a 
half-pint  of  thick,  creamy  pus  was  evacuated  from  the 
middle  palmar  space.  There  was  no  pus  in  the  thenar 
space  or  the  tendon  sheaths. 

Following  the  operation  the  temperature  varied  from 
99°  to  101°;  pulse,  84  to  100.  During  the  second  day 
it  is  noted  on  the  history  sheet:  "Patient  removed  Bier 
constrictor  during  night,  has  involuntary  urination.  Hand 
and  forearm  violently  inflamed,  arm  not  involved.  Am 
not  sure  whether  mental  symptoms  are  due  to  kidneys 
or  hand." 

That  night  the  temperature  rose  to  102°,  but  varied 
from  this  to  normal  during  the  next  day.  The  pulse 
averaged  100.  During  the  fourth  day  the  temperature 
varied  from  normal  to  100°.  The  pulse  was  still  not 
rapid,  although  the  patient  was  delirious  and  there  was 
evidently  a  metastatic  infection  in  the  tendon  sheath 
of  the  extensor  hallucis  of  right  leg.  Operation,  January 
29,  1909.  Incision  in  palm  enlarged  and  incision  on 
lateral  surface  of  forearm  to  secure  drainage.  Consider- 
able pus  evacuated.  Incision  over  right  fibula  near  ankle 
and  into  tendon  sheath  of  extensor  hallucis.  Watery 
pus  evacuated. 

The  pulse  and  temperature  ran  about  the  same  as 
before.  The  highest  pulse  recorded  is  120,  and  the  highest 
temperature,  101.4°.  The  mental  condition  grew  worse, 
and  the  patient  died  two  days  later. 

Another  fatal  case,  which  I  saw  in  consultation 
with  Dr.  A.  B.  Eustace,  to  whom  I  am  indebted  for 
the  history  and  report  of  the  findings  at  postmortem, 
at  which  I  was  permitted  to  be  present  through  the 
courtesy  of  Dr.  W.  H.  Hunter  and  Dr.  Eustace,  is 
a  very  valuable  one,  since  the  positions  of  pus  shown 


LYMPHANGITIS   WITH  SYSTEMIC  INVOLVEMENT     349 

at  the  postmortem  fully  corroborate  the  findings 
which  I  have  noted  clinically  in  the  cases  which 
recovered,  as  well  as  verify  the  results  which  I  obtained 
experimentally  by  injections  of  the  forearm.  It 
emphasizes  also  the  difficulty  of  differentiating  these 
cases  at  times  from  rheumatism.  Unfortunately, 
I  have  not  the  exact  age,  but  the  patient  was  in  the 
neighborhood  of  fifty  years,  which  again  draws  atten- 
tion to  the  influence  of  age  in  these  fatalities. 

Here  the  primary  focus  was  in  the  ulnar  bursa. 
Owing  to  the  difficulty  of  diagnosis,  the  diagnosis 
and,  consequently,  the  proper  treatment  were  held 
in  abeyance  several  days. 

CASE  XXII. — Miss  E.  J.,  Cook  County  Hospital. 
Patient  entered  on  June  I,  1908.  Attending  surgeon, 
Dr.  E.  Wyllys  Andrews;  house  physicians,  Drs.  Eusta'ce 
and  Courtenay. 

History  of  Present  Trouble:  Patient  enters  hospital 
complaining  of  pain  and  swelling  in  right  wrist  and  hand. 
Upon  questioning  she  says  she  awoke  last  Friday  night 
with  pain  in  this  joint.  There  was  a  sense  of  heat  and 
the  joint  was  particularly  painful  on  motion.  Her  sleep 
was  disturbed,  and  by  the  next  morning  she  says  her 
wrist  was  notably  swollen  and  red.  Tenderness  was 
pronounced  over  the  end  of  the  ulna  posteriorly,  and 
also  anteriorly  over  both  bones  of  the  forearm  at  their 
carpal  articulation. 

A  history  of  any  previous  injury,  fall,  infection,  or 
arthritis  of  any  sort  is  denied.  Accompanying  this  the 
patient  denies  other  symptoms  of  any  sort,  but  since 
Friday  the  joint  has  become  swollen  and  progressively 
worse,  the  pain  is  agonizing,  and  there  is  an  indefinite 
history  of  chills  and  fever. 

Previous  Illnesses:  For  the  past  ten  years  she  has 
suffered  intermittently  from  articular  rheumatism,  and 
three  weeks  ago  she  was  a  patient  in  this  institution 
for  otitis  media  and  discharged  after  a  period  of  two 
weeks'  treatment. 

Physical   Examination:      Negative    except    as    follows: 


350      SYMPTOMS  AND  SIGNS  OF  LYMPHANGITIS 

The  right  wrist  and  hand  are  greatly  swollen  and  inflamed, 
the  wrist  on  both  surfaces,  the  hand  on  the  posterior 
surface  only.  The  swelling  is  localized  to  the  wrist-joint 
and  extends  up  the  forearm  for  about  three  inches.  The 
fingers  are  in  semiflexion,  and  the  slightest  movement 
causes  extreme  pain.  There  is  also  extreme  tenderness 
around  the  wrist-joint,  which  is  also  very  painful  upon 
motion.  Lymphatic  involvement  is  lacking,  and  appar- 
ently there  is  no  tendon-sheath  involvement.  No  atrium 
of  infection  can  be  found,  and  shoulder  and  elbow-joints 
are  not  involved.  The  left  arm  is  not  involved,  though 
some  pain  is  elicited  on  motion  of  shoulder.  Fingers 
give  evidence  of  a  rheumatic  diathesis  (G.  T.  Courtenay). 

Pulse.  Temperature.  Respirations. 

June  2,  1908     ....  94  102°  24 

June  2,  1908     ....         103  102°  24 

June  2,  1908 104  101  °  22 

White  blood  count  on  entrance,  8200.  Patient  given 
large  doses  of  sodium  salicylate. 

Operation,  June  4,  1908.  Incision  down  to  ulnar 
bursa  and  one  above  the  anterior  annular  ligament  on 
ulnar  side.  A  hemostat  was  forced  through  to  the  radial 
side  and  pus  evacuated.  Gauze  drainage  and  hot  boric 
dressings.  Bier's  constrictor  applied  to  arm  (A.  B. 
Eustace) . 

Operation,  June  7,  1908.  Two  incisions  on  the  flexor 
surface  of  the  forearm  just  above  the  wrist-joint  and 
another  three  inches  above  this.  These  were  each  one 
inch  long  and  penetrated  to  the  flexor  tendons;  openings 
connected  with  gauze  drainage  (G.  T.  Courtenay). 

Operation,  June  15,  1908.  Incision  along  ulnar  bursa 
enlarged  and  a  large  amount  of  pus  evacuated.  Knee- 
joint  aspirated  and  pus  obtained.  Two  per  cent,  solu- 
tion of  formalin  in  glycerin  injected.  Died  June  16, 
1908.  Autopsy  by  Dr.  A.  B.  Eustace  and  Dr.  Allen  B. 
Kanavel. 

Hand  and  Arm:  Extensor  surface:  On  opening  back 
of  forearm  a  small  focus  of  pus  is  found  at  junction  of 
lower  quarters  of  forearm.  This  communicates  with 
incision  in  skin  on  side.  There  was  no  pus  between 
extensor  communis  and  deeper  tissues,  except  at  point 


LYMPHANGITIS   WITH  SYSTEilKi  ^INVOLVEMENT   351 

pjjvr/.r  1J "  '  ^rjFf. 77-f 

indicated,  and  this  pus  extended  down  underneath  this 

muscle. 

No  pus  found  subcutaneously  on  the  dorsum  of  the 
hand  except  at  the  wrist-joint,  and  this  could  be  traced 
into  the  tendon  sheath  of  the  extensor  communis  digi- 
torum.  The  tendon  sheaths  of  the  extensor  radialis 
longior  and  brevior  also  showed  pus.  The  tendon  of  the 
extensor  carpi  ulnaris  was  free  from  pus. 

Back  of  the  sheath  of  the  extensor  communis  digi- 
torum  is  seen  an  opening  extending  down  to  the  carpal 
bones.  Articulation  between  the  carpal  bones  and  the 
radius  found  to  contain  a  slight  amount  of  pus.  Articu- 
lation between  proximal  and  distal  row  of  bones  also 
contains  a  slight  amount  of  pus.  No  pus  found  under 
tendons  on  the  back  of  the  hand,  communicating  with 
joint. 

Flexor  Surface:  Incision  found  in  median  line,  at 
junction  of  lower  and  middle  thirds  through  skin  imme- 
diately above  annular  ligament,  and  on  either  side  at 
and  above  articular  surface. 

Incision  on  ulnar  side  extended  upward  for  a  distance 
of  two  and  one-half  inches.  Incision  also  in  palm  of 
hand  on  ulnar  side  lengthwise  along  inner  edge  of  hypo- 
thenar  eminence.  The  hand  as  a  whole  does  not  appear 
to  be  greatly  swollen,  and  some  concavity  appears  in  the 
middle  of  the  palm. 

Upon  opening  the  palm  of  the  hand,  ulnar  bursa  found 
to  be  filled  with  pus  and  tendon  sheath  of  little  finger 
also  filled  with  pus.  Rupture  had  occurred  into  the  fore- 
arm at  a  point  one  and  one-half  inches  above  the  articular 
surface  of  the  wrist-joint.  Middle  palmar  space  opened 
and  found  to  be  filled  with  pus.  Thenar  space  free  from 
pus.  Tendon  sheath  of  flexor  longus  pollicis  free  from 
pus.  Radial  bursa,  no  pus  found  at  any  point.  Above 
the  wrist-joint,  pus  is  found  in  sheath  passing  up  under- 
neath tendons  from  midpalmar  space. 

Forearm:  Pus  is  found  underneath  the  flexor  pro- 
fundus  digitorum.  Pus  extended  up  the  forearm  in 
juxtaposition  to  ulna  up  to  the  elbow  lying  immediately 
on  the  ulna. 

Pus  also  found  along  ulnar  artery  for  a  distance  of 
about  one  and  one-half  inches  at  middle  of  forearm, 


352^  SYPOM^  :v4^  $IGNS  OF  LYMPHANGITIS 

put  <^id  x{iqt  \  £Kte\i<3  Vp  ^to  the  elbow.  A  small  opening 
L"  \  i  ^  1s^  tliscernible  at  lower  end  of  ulna  connecting  joint  with 
ulnar  bursa.  It  could  not  be  determined  definitely 
whether  this  opening  was  made  by  dissection  or  was 
present  before. 

No  opening  was  demonstrable  between  wrist-joint 
and  radial  bursa. 

No  necrosis  of  bones  of  wrist- joint;  tendon  sheath  of 
ring  finger  intact;  tendon  sheath  of  middle  finger  intact; 
tendon  sheath  of  index  finger  intact.  Pus  extended  out 
in  little  finger  to  proximal  interphalangeal  joint.  Peri- 
osteum of  radius  and  ulna  not  destroyed.  No  pus  in 
elbow-joint.  'Axillary  glands  barely  palpable. 

Heart:     No  evidence  of  pericarditis  or  adhesions. 

Pleural  Cavities:  Left,  no  adhesions;  right,  few  adhe- 
sions at  apex. 

Lungs:  Left,  crepitates,  no  consideration,  frothy  red 
serum  exudes,  apparently  normal;  right,  answers  above 
description. 

Liver:  Gall-bladder  distended  and  filled  with  fluid. 
Liver  is  mottled  on  cut  sections,  the  interlobular  mark- 
ings faint,  no  evidence  of  miliary  abscesses.  Tissues 
very  soft  and  friable  and  color  is  paler  than  normal. 

Spleen:  Enlarged  in  size,  is  soft  and  friable.  Cuts 
like  butter.  Miliary  abscesses  found. 

Kidneys:  Soft  and  friable.  Capsules  strip  with  some 
difficulty  and  leave  parts  of  the  cortex.  Cortex  is  almost 
obliterated,  as  are  also  the  pyramids,  but  here  and  there 
a  distinct  outline  of  a  pyramid  may  be  found. 

Right  Knee-joint:  Filled  with  thick  yellow  pus,  small 
ecchymotic  areas  in  periosteum. 

Cultures  before  and  after  death  showed  Staphylococcus 
albus. 

Microscopic  examination  of  the  various  organs  showed 
acute  parenchymatous  degeneration. 

POSTMORTEM  STATISTICS. — Tornier  reports  ten  fatal 
cases  upon  which  postmortem  had  been  made.  The 
findings  were  as  follows: 


LYMPHANGITIS   WITH  SYSTEMIC  INVOLVEMENT     353 

Cases. 

Acute  hyperplasia  of  spleen 9 

Parenchymatous  nephritis         7 

Bronchopneumonia 5 

Lung  abscesses 2 

Empyema 2 

Acute  pericarditis I 

Hemorrhagic  pleuritis I 

Subpericardial,  subpleural,  and  cecal  hemorrhages   ...  4 

Abscess  of  kidney 2 

Abscess  of  liver 2 

Thrombosis  of  veins 2 

Icterus 3 


The  age  of  the  fatal  cases  averaged  forty-three  and 
eight-tenths  years. 

THROMBOPHLEBITIS. — Either  associated  with  lym- 
phangitis or  as  a  distinct  process  we  may  have  throm- 
bophlebitis. The  symptoms  and  signs  here  would 
be  the  same  as  those  occurring  with  thrombophlebitis 
of  the  leg,  where  it  is  more  common.  Generally  begin- 
ning with  a  localized  infection,  the  process  extends 
into  a  vein.  The  severity  of  the  symptoms  depends 
upon  the  extent  of  the  process,  varying  from  those 
of  a  mild  septicemia  with  localized  evidences  to  most 
severe  toxemia,  metastatic  abscesses,  and  death.  This 
can  best  be  illustrated  by  a  case  which  came  under 
my  care  at  the  Post-Graduate  Hospital. 

CASE  XXIII. — Mr.  L.,  aged  twenty-five  years.  Post- 
Graduate  Hospital,  March  5,  1909  (Fig.  118). 

Diagnosis. — Suppurative  phlebitis  of  veins  of  dorsum 
of  hand. 

The  patient  applied  to  the  hospital  with  a  small  infection 
upon  the,  dorsum  of  the  hand,  apparently  carbuncular 
in  nature.  The  infection  had  been  present  for  four  days, 
and  was  gradually  increasing  in  size.  The  hand  was  con- 
siderably swollen,  and  there  was  an  area  of  swelling 
and  induration  extending  up  the  dorsum  of  the  forearm 
for  three  inches.  Temperature,  101°;  pulse,  94;  urine 
negative. 
23 


354      SYMPTOMS  AND  SIGNS  OF  LYMPHANGITIS 


Operation. — Gas  anesthesia.  A  crucial  incision  was 
made  over  the  area  and  an  accumulation  of  thick  pus 
and  seminecrotic  tissue  evacuated.  The  indurated  area 
extending  up  the  dorsum  of  the  forearm  was  found  to  be 
a  large  vein  which  was  filled  with  a  septic  thrombus. 
This  was  opened  for  four  inches  up  on  the  area,  when  a 
free  regurgitation  of  venous  blood  was  secured.  The 
vessel  was  tied  and  the  wound  left  open  (Fig.  118).  A 
Bier  constrictor  was  applied. 

FIG.  118 


Photograph  of  a  hand  of  a  patient  with  thrombophlebitis.    Wound  is  left 
open,  as  is  seen  in  photograph.    (Case  XXIII.) 

Following  the  operation  the  local  area  granulated 
freely,  and  rapidly  went  on  to  complete  repair.  Over 
a  period  of  four  weeks,  however,  the  patient  developed 
three  metastatic  abscesses  in  various  parts  of  the  body, 
which  were  opened.  Fortunately,  none  developed 
in  the  bones  or  viscera,  at  least,  so  far  as  was  discovered. 
The  temperature  and  pulse  were  never  high,  but  still 
fluctuated  with  the  development  of  the  foci.  The 
patient  ultimately  made  a  complete  recovery. 


LYMPHANGITIS  WITH   SYSTEMIC  INVOLVEMENT    355 


The  symptoms  and  signs  appear  as  follows:  A 
red  line  running  up  the  forearm  corresponding  to 
the  anatomical  distribution  of  the  lymphatic  vessels 
draining  the  area  of  primary  infection.  There  may 
be  no  local  reaction  and  little  swelling;  generally, 
however,  there  is  slight  swelling  accompanied  by  dull 
pain.  In  the  less  severe  cases  considerable  edema 
will  develop  on  the  dorsum  and  the  pain  will  be  very 
severe.  Early  there  is  little  tenderness.  Generally, 
after  twenty-four  hours,  tenderness  may  develop  in 
the  extremity  over  the  glands  involved,  i.  e.,  the 
epitrochlear  or  axillary. 

Systemic  symptoms  vary  in  the  widest  limits.  In 
some  cases  very  early  the  patient  presents  evidences 
of  severe  toxemia,  with  a  chill,  high  or  low  tempera- 
ture, headache,  anorexia,  and  prostration.  Four 
types  are  seen:  A,  simple  acute  lymphangitis:  This 
is  a  type  with  few  systemic  symptoms  and  a  rapid 
disappearance  of  lymphatic  inflammation.  B,  acute 
lymphangitis  with  minor  local  complications:  Here 
the  symptoms  subside  slowly  ending  in  an  abscess 
at  the  site  of  inoculation  or  in  the  gland  area.  C, 
acute  lymphangitis  with  serious  local  complications: 
Here  we  have  such  complications  as  tenosynovitis 
and  subcutaneous  phlegmons.  D,  acute  lymphangitis 
with  systemic  involvement:  In  this  group  we  have 
the  most  alarming  systemic  symptoms  with  little 
local  evidence  of  disease  and  a  rapidly  fatal  issue. 

Phlegmonous  lymphangitis  is  one  of  the  most 
serious  types  of  infection  seen.  Here  we  have  profound 
toxemia,  a  greatly  swollen  forearm,  board-like  indura- 
tions and  blisters  on  the  skin.  The  subcutaneous 
tissue  sloughs  en  masse.  The  superficial  veins  become 
thrombosed  and  the  patient  dies  from  toxemia  or  some 


356      SYMPTOMS  AND  SIGNS  OF  LYMPHANGITIS 

of  the  severer  complications  of  infection,  such  as  sepsis, 
meningitis,  pneumonia,  etc. 

Localization  takes  place  in  lymphangitis  in  from 
10  to  15  per  cent,  of  the  cases.  The  sites  are  ordinarily 
the  tendon  sheaths,  dorsum  of  the  hand,  the  dorsum 
of  the  forearm,  the  epitrochlear  region,  and  the  axilla. 

Systemic  infection  is  more  likely  to  occur  in  indi- 
viduals over  thirty-five  years  of  age  and  is  more 
likely  to  follow  infections  of  the  thumb,  index  or  little 
finger,  especially  the  middle  finger.  In  these  cases 
the  onset  is  brusque,  there  is  little  local  reaction 
along  the  lymphatic  or  glandular  region,  prostration 
becomes  profound,  and  death  rapidly  ensues. 

Deep  lymphangitis  is  on  the  whole  rather  a  rare 
complication.  If  present,  the  pus  is  found  in  the 
deeper  portions  in  the  pockets  already  enumerated. 

Thrombophlebitis  may  occur  associated  with  lym- 
phangitis or  as  a  distinct  process. 


CHAPTER  XXII. 

PROGNOSIS   IN   LYMPHATIC   INFECTIONS. 

THE  prognosis  as  to  life  in  lymphatic  infections  is 
dependent  upon  so  many  factors  over  which  we  have 
no  control  that  it  is  extremely  difficult  to  arrive  at 
any  satisfactory  statement  concerning  it.  In  Hel- 
ferich's  clinic,  in  a  series  of  nearly  200  severe  infections 
of  the  hand,  a  fatal  issue  followed  in  22  per  cent. 
These  statistics  comprise  all  types  of  infection  of  the 
hand,  and  are  limited  to  extensive  abscesses,  teno- 
synovitis,  and  severe  lymphangitis.  This  percentage 
is  certainly  high  for  patients  in  the  ordinary  walks 
of  life.  In  my  own  experience  the  mortality  in  these 
severe  cases  will  average  about  3  or  4  per  cent. 

Of  the  factors  concerned,  of  chief  importance  is  the 
age  of  the  individual.  The  average  age  of  fatal  cases 
is  in  the  neighborhood  of  forty-five  years.  The  general 
state  of  the  patient's  resistance  is  of  importance. 
For  instance,  in  Cook  County  Hospital,  where  the 
social  derelicts  are  found,  the  mortality  is  much  higher 
than  in  private  hospitals.  The  presence  of  nephritis 
in  the  various  forms  or  of  any  of  the  chronic  system 
diseases  has  a  marked  influence  upon  the  prognosis. 

If  the  symptoms  of  toxemia  do  not  subside  within 
three  days,  if  no  local  process  has  developed,  or  within 
two  days  after  opening  such  foci,  anxiety  should  be 
felt  for  the  patient.  Either  there  is  a  local  extension, 
or  the  patient  is  not  reacting.  The  part  affected  has 
some  influence  upon  the  prognosis.  The  presence  of 
an  infection  beginning  in  the  little  finger  or  the  thumb 
causes  fear  of  tenosynovitis  with  a  prolonged  con- 
valescence, while  an  involvement  of  the  index  or  middle 
finger  may  early  lead  to  severe  systemic  symptoms. 
The  type  of  germ  in  a  given  patient  is  also  of  great 


358         PROGNOSIS  IN  LYMPHATIC  INFECTIONS 

importance  from  a  prognostic  standpoint,  since  it 
is  well  known  that  the  gravest  infections  arise  from 
the  streptococcus  and  certain  of  the  gas  bacilli. 
Again,  a  brusque  onset  with  high  temperature  and 
chills  speaks  for  a  serious  infection. 

To  my  mind  the  prognosis  is  influenced  somewhat 
by  the  character  of  treatment.  If  ill-advised  and 
premature  incisions  are  made,  what  might  have  been 
a  moderate  infection  may  be  turned  into  a  severe 
type.  Many  attempts  have  been  made  to  secure 
data  upon  which  prognosis  may  be  made  by  an  exami- 
nation of  the  blood,  and  this  is  of  some  general  value. 
One  of  the  latest  and  most  complete  researches  is 
that  of  Zangmeister.1 

The  first  conclusion  which  the  author  derived 
from  a  large  series  of  blood  counts  was  that  the  numeric 
fluctuations  of  the  single  leukocyte  forms  per  cubic 
centimeter  of  blood  show  the  real  condition  of  the 
patient,  but  not  the  numerical  ratio  of  the  variety 
of  forms  to  each  other.  To  make  a  prognosis  in  strep- 
tococcus infections  from  the  blood  picture  it  is  impor- 
tant to  know  that  the  conditions  change  completely 
after  the  first  twenty-four  hours  after  the  infection, 
and  that  the  findings  during  the  first  twenty-four 
hours  do  not  apply  later  on. 

In  monkeys  he  found  the  following  after  the  first 
twenty-four  hours  after  infection: 

1.  In   infections  rapidly  fatal,   all  forms  of  leuko- 
cytes decline  quickly  in  number. 

2.  In   infections   fatal   after   a   few  days   he   found 
a  tardy  and  small  increase  of  the  mononuclear  neu- 
trophilic    cells    and    a    decrease    of    the    polynuclear 
neutrophilic   and   eosinophilic   cells   and   lymphocytes 
in  the  first  eighteen  hours. 

3.  In    infections    not    fatal    he    found    an    increase 
of  the  mononuclear  neutrophilic  cells  during  the  first 

1  Monatsschrift  f.  Geb.  und  Gynak.,  Band  xxxi,  Heft  i. 


PROGNOSIS  IN  LYMPHATIC  INFECTIONS         359 

six  hours  after  the  infection;   from   then  a  decrease. 
The  polynuclear  and  eosinophilic  cells  and   lympho- 
cytes increase  in  number  after  the  first  six  hours. 
Therefore  good  prognostic  symptoms  are: 

(a)  An    immediate    increase    of    the    mononuclear 
neutrophilic    cells    for    the    first    six    or    eight    hours, 
with  a  following  decline. 

(b)  An   increase  of  the   polynuclear  cells  after  six 
hours,   after  a  short  decline. 

(c)  An  increase  of  the  eosinophilic  cells  inside  the 
first  twenty-four  hours. 

(d)  An    increase   of    the    lymphocytes    in    the    first 
twenty-four  hours. 

The  prognosis  is  bad  (i)  if  the  mononuclear  cells 
show  no  increase  or  a  decrease  in  the  first  eight  hours; 
(2)  if  there  is  a  continuous  decrease  of  the  polynuclear 
cells  and  lymphocytes. 

In  a  large  series  of  the  blood  countings  before  and 
immediately  after  operations  the  author  found  that 
these  findings  in  monkeys  are  parallel  to  those  in 
man. 

After  the  first  twenty-four  hours  conditions  are 
changed,  and  the  curve  of  the  eosinophilic  cells,  of 
the  lymphocytes,  and  of  the  mononuclear  neutro- 
philic cells  is  of  no  importance.  A  continuous  decrease 
of  the  polynuclear  cells  or  their  remaining  stationary 
is  a  bad  prognostic  sign.  In  less  severe  infections  they 
will  rapidly  or  at  least  slowly  increase. 

His  final  conclusions  are: 

"We  are  allowed  to  make  a  good  prognosis  inside 
the  first  twenty-four  hours  after  the  infection  if  we 
find  (a)  an  immediate  increase  of  the  mononuclear 
neutrophilic  cells  with  a  slow  decrease  after  eight 
hours;  (b)  an  increase  of  the  polynuclear  ce'lls  after 
eight  hours  after  a  small  decrease. 

"We  have  to  deal  with  a  fatal  infection  (a)  if  the 
mononuclear  cells  increase  after  the  first  twenty 


360         PROGNOSIS  IN  LYMPHATIC  INFECTIONS 

hours;  (&)  if  the  mononuclear  cells  do  not  increase 
at  all  or  decrease  immediately  after  infection;  (c) 
if  the  polynuclear  cells  decrease  constantly. 

He  made  one  blood  count  before,  one  six  to  eight 
hours,  and  one  twenty  to  twenty-four  hours  after 
the  operation  respectively. 

After  twenty-four  hours,  the  number  of  polynu- 
clear cells  only  is  of  importance;  if  they  are  below 
normal  and  keep  on  decreasing  the  prognosis  is  bad, 
and  vice  versa. 

By  injecting  a  person  with  dead  streptococci, 
Zangmeister  was  able  to  test  the  resisting  power  of 
the  person  against  streptococcus  infection—  "Resisteur 
probe."  If  the  resisting  power  is  reduced,  the  mono- 
nuclear  cells  after  the  injection  will  show  no  increase  or 
the  increase  comes  late ;  the  polynuclear  cells  will  show 
no  increase  soon  after  the  infection,  or  a  decrease. 

What  may  be  said  regarding  the  probability  of 
local  complications?  It  is  impossible  to  arrive  at  any 
just  estimation  as  to  the  probability  of  the  develop- 
ment of  tenosynovitis  and  fascial-space  abscesses. 
In  my  experience  those  patients  showing  a  brusque 
onset  with  great  pain  are  more  likely  to  have  such 
complications.  The  tenosynovitis  is  more  likely  to 
develop  from  infection  implanted  on  the  volar  sur- 
face of  the  distal  or  middle  phalanx.  Local  accumula- 
tions on  the  dorsum  of  the  web  between  the  fingers 
are  apt  to  develop  from  the  callus  cracks  at  the  distal 
portion  of  the  palm.  Dorsal  subcutaneous  thenar 
abscesses  appear  in  infections  of  the  thenar  palmar 
surface.  Subcutaneous  abscesses  above  the  anterior 
annular  ligament  often  occur  in  connection  with 
tenosynovitis.  Ill-advised  incision  may  determine  the 
localization  of  infection  in  various  spaces.  In  several 
patients  whom  I  have  seen  in  consultation,  I  feel 
sure  that  the  tenosynovitis  which  developed  was 
directly  due  to  the  primary  incision. 


CHAPTER  XXIII. 

THE    TREATMENT    OF    LYMPHATIC    INFEC- 
TIONS—GENERAL  DISCUSSION. 

THE  treatment  of  lymphatic  infections  is  based 
Upon  two  principles — conservatism  and  conservation. 
In  no  type  can  more  harm  be  done  by  ill-advised 
incisions  than  in  this.  The  position  of  masterful 
inactivity  is  most  difficult  to  maintain,  and  yet  the 
surgeon  is  constantly  aware  that  his  tendency  to  incise 
is  due  to  his  desire  "to  do  something"  rather  than 
an  exact  knowledge  as  to  what  to  do.  We  therefore 
use  local  measures  designed  to  wall  off  and  overcome 
the  infection,  combined  with  procedures  designed  to 
support  the  system  and  increase  its  resisting  powers. 
In  the  ordinary  case,  until  some  localization  is  present, 
we  apply  hot,  moist  dressings,  insist  upon  local  and 
systemic  rest,  combined  with  cathartics  and  sedatives, 
as  the  case  may  demand. 

DISCUSSION   OF  VARIOUS   PROCEDURES. 

LOCAL. — Hot,  Moist  Dressings. — Many  forms  of 
such  applications  are  in  use  and  have  a  vogue  for  a 
time.  It  is  my  personal  opinion  that  such  applications 
owe  their  value  more  to  the  moist  heat  than  to  the 
drug  with  which  they  are  combined.  It  is  my  custom 
to  use  boric  acid  in  saturated  solution.  I  am  aware 
that  many  studies  have  been  made  from  which  con- 
clusions were  drawn  as  to  its  antiseptic  property 
when  absorbed  by  the  blood  stream.  It  is  probable 
that  it  would  be  unjust  to  say  that  such  minute 
quantities  as  have  been  demonstrated  in  the  blood, 


and  consequently  in  the  urine,  can  have  no  effect, 
since  no  one  knows  the  effect  of  combining  small 
proportions  of  any  chemical  solution  with  blood  serum 
in  vivo,  although  in  the  test-tube  such  combinations 
may  be  shown  to  be  without  value.  It  would  seem 
more  reasonable  to  ascribe  the  beneficial  value  of 
such  applications  to  the  dilatation  of  the  capillaries 
and  the  bringing  of  more  blood  to  the  part,  favoring 
the  walling  off  of  the  infection. 

Peculiar  value  has  been  ascribed  by  various  sur- 
geons to  bichloride  solution,  creolin,  almost  all  of  the 
various  antiseptics,  ichthyol,  alcohol,  etc.  Unless 
they  are  used  for  a  particular  purpose,  however,  it 
would  seem  that  hot  boric  solution  will  be  as  efficient 
as  any. 

Certain  special  purposes  may  be  secured  by  special 
solutions.  In  those  cases  in  which  there  is  a  foul  odor, 
a  I  to  2000  or  i  to  4000  potassium  permanganate 
solution  will  be  found  of  value.  We  may  secure  some 
slight  local  antiseptic  property  in  the  use  of  alcohol 
dressings,  using  a  30  to  50  per  cent,  solution.  This 
should  not  be  kept  up  any  length  of  time.  It  is  cer- 
tainly not  necessary  to  warn  the  profession  against 
the  use  of  carbolic  acid  solution  in  any  strength.  The 
frequency  with  which  carbolic  acid  gangrene  is  seen, 
however,  leads  me  to  urge  upon  physicians  the  necessity 
of  informing  patients  of  the  danger  of  this  remedy, 
which  is  so  often  the  home  application  for  all  cuts  and 
injuries. 

The  method  of  applying  hot  boric  dressings  has  been 
discussed  on  p.  72.  They  are  so  applied  as  to  cover 
the  entire  forearm  and  arm  in  the  severe  cases.  It 
is  a  good  rule  to  make  the  dressing  much  larger  than 
the  condition  would  seem  to  call  for.  These  hot, 
moist  dressings  are  to  be  used  until  the  red  line  of 
lymphatic  involvement  has  entirely  disappeared  and 


DISCUSSION  OF  VARIOUS  PROCEDURES         363 

any  acute  edema  has  begun  to  subside,  at  which  time 
a  change  should  be  made  to  a  dry  dressing  of  some 
kind. 

Rest. — Both  local  and  systemic  rest  should  be 
insisted  upon,  especially  in  severe  infections.  The 
local  rest  is  of  special  value  in  a  prophylactic  sense, 
since  every  movement  of  the  fingers  or  hand  tends 
to  favor  lymphatic  circulation  and  hence  to  favor 
dissemination  of  the  infection.  Von  Volkmann  and 
others  have  advised  suspending  the  arm  so  that  the 
hand  is  elevated.  It  does  not  seem  that  this  would 
be  of  value  except  to  relieve  the  pain  of  a  congestion, 
and  it  has  not  seemed  to  me  to  influence  the  course 
favorably. 

The  Bier  Treatment. — The  place  of  the  Bier  treat- 
ment in  infections  of  the  hand  has  already  been 
touched  upon  (p.  71).  In  these  lymphatic  infections 
I  have  used  it  only  in  the  same  sense  that  we  would  use 
a  ligature  to  prevent  the  rapid  absorption  of  any 
poison,  as,  for  instance,  in  the  slow  absorption  per- 
mitted in  snake  bites.  It,  therefore,  would  find  a 
place  in  the  early  hours  of  a  virulent  lymphatic 
infection  in  which  the  system  may  be  receiving  large 
doses  of  virulent  toxins  without  seeming  to  have  the 
reactive  power  necessary  to  wall  off  the  infection. 
Here  the  constrictor  is  applied  for  from  twelve  to 
eighteen  hours,  tight  enough  to  secure  a  marked  edema. 
This  is  done  with  the  hope  that  the  lack  of  reaction 
upon  the  part  of  the  system  is  due  in  part  to  the  fact 
that  it  is  overwhelmed,  and  that  if  small  doses  are 
allowed  to  enter  the  system  a  marked  antitoxin  will 
be  developed  which  will  be  able  to  withstand  the  toxin 
if  its  entrance  into  the  system  is  spread  over  some 
time.  Whether  or  not  diapedesis  of  leukocytes  in 
these  infections  is  favored  by  passive  congestion  is 
a  moot  question. 


364     THE  TREATMENT  OF  LYMPHATIC  INFECTIONS 

The  method  of  applying  the  bandage  is  as  follows: 
A  Martin  bandage  two  inches  wide  is  used.  The 
bandage  is  begun  at  a  point  slightly  above  the  elbow 
and  carried  to  a  point  slightly  below  the  axilla.  Sev- 
eral turns  are  carried  about  the  arm,  so  made  as  to 
preserve  an  equable  pressure  throughout.  The  pres- 
sure should  be  sufficient  to  produce  a  moderate  edema 
in  an  hour,  and  should  not  be  sufficient  to  produce 
pain.  The  method  used  by  some  of  wrapping  a  towel 
about  the  arm  and  securing  constriction  by  a  rubber 
tube  or  narrow  rubber  band  is  unwise,  since  it  will 
cause  considerable  pain  and  is  more  likely  to  produce 
nerve  injury.  After  the  bandage  has  been  in  place 
twelve  to  eighteen  hours  it  is  removed  and  replaced 
in  a  couple  of  hours  if  the  toxemia  is  still  high.  Ordi- 
narily, one  or  two  eighteen-hour  periods  is  all  I  have 
found  of  advantage  in  these  cases. 

Incisions. — There  may  be  some  difference  in  opinion 
as  to  the  advisability  of  these  under  certain  conditions. 

There  are  those  who  teach  that  an  incision  made 
at  the  point  of  great  pain  and  tenderness  when  it  is 
the  site  of  the  primary  infection  will  be  of  value. 
They  maintain  that  such  an  incision  if  it  does  not 
evacuate  pus  favors  drainage  about  the  site  of  the  in- 
fection, and  that  the  escaping  serum  carries  off  the 
bacteria.  It  is  my  own  belief  that  this  hope  is  seldom 
justified,  and  that  the  incision  simply  opens  new 
lymphatics  for  infection  and  fails  to  reach  the  bacteria 
which  have  already  entered  the  lymphatic  stream 
and  are  multiplying  some  distance  from  the  site  of 
entrance.  Therefore,  the  prophylactic  incision  fails 
of  its  purpose  and  may  do  much  harm  by  producing 
complications. 

Shall  incisions  be  made  along  the  line  of  lymphatics? 
In  those  cases  in  which  there  is  one  or  possibly  two 
red  lines  of  lymphatic  involvement  running  up  the 


DISCUSSION  OF  VARIOUS  PROCEDURES          365 

arm  the  advice  to  make  a  transverse  incision  through 
the  skin  and  subcutaneous  tissue,  so  as  to  prevent 
the  channel  from  carrying  more  toxin,  seems  logical, 
and  I  have  carried  it  out  in  a  few  cases.  I  am  con- 
vinced, however,  that  the  procedure  is  likely  to  do 
more  harm  than  good,  since  it  pours  out  into  the  wound 
the  virulent  bacteria  and  toxins  which  at  the  end  of  a 
few  hours  begin  to  be  absorbed  in  greater  amount 
than  before.  The  picture  presented  by  this  procedure 
is  very  characteristic.  Within  an  hour  after  the  cut 
is  made  the  part  proximal  to  the  incision  becomes 
pale,  the  red  lymphatic  disappears,  and  the  surgeon 
feels  that  his  procedure  has  been  justified  by  the 
results.  At  the  end  of  a  few  hours,  however,  it  is 
seen  that  the  portion  distal  to  the  incision  has  begun 
to  assume  a  reddish  tinge,  and  shortly  a  consider- 
able area  takes  on  the  characteristic  appearance  of 
an  erysipelas,  with  an  aggravation  of  the  symptoms. 

In  other  instances  the  little  lacunae  found  in  the 
course  of  the  lymphatic  vessels  (see  p.  327)  show  small 
areas  the  size  of  a  bean  in  the  course  of  the  lymphatics, 
at  which  sites  there  is  a  local  swelling  and  edema. 
These  are  most  common  on  the  dorsum  of  the  hand. 
The  thoughtless  are  inclined  to  incise  these  under  the 
impression  that  localization  will  be  found  there  and 
that  drainage  is  indicated.  If  incision  is  made,  how- 
ever, only  a  small  amount  of  serum  will  exude,  and  in 
the  severe  cases  the  procedure  is  generally  followed 
by  a  chill  and  rise  of  fever  within  an  hour  or  two, 
sometimes  to  an  alarming  degree,  while  the  procedure 
is  detrimental  rather  than  beneficial  to  the  ultimate 
course. 

If  incision  is  made  in  these  cases  for  any  cause, 
the  possibility  of  spreading  the  infection  must  be  borne 
in  mind  and  one  should  seek  at  least  to  prevent 
rapid  absorption.  This  is  done  by  keeping  the  arm 


366     THE  TREATMENT  OF  LYMPHATIC  INFECTIONS 

absolutely  at  rest  and  applying  a  Bier  constrictor 
to  the  arm.  This  should  be  left  on  for  from  twelve 
to  eighteen  hours.  These  incisions  will  be  called  for 
in  those  cases  in  which  localization  in  the  tendon 
sheaths  or  in  the  subcutaneous  tissues  has  taken  place, 
as,  for  instance,  on  the  back  of  the  forearm  or  about 
the  glands.  (For  a  discussion  of  these,  see  p.  370.) 

SYSTEMIC  TREATMENT. — Antagonistic  Drugs. — Vari- 
ous drugs  have  been  vaunted  from  time  to  time  as 
of  exceptional  value  in  septic  conditions.  They  may 
be  classified  as  those  designed  to  destroy  bacteria 
and  those  to  neutralize  the  toxin.  The  value  of  any 
of  them  is  questionable.  Quinine  has  been  used  for 
many  years,  and  if  it  were  of  marked  value  sufficient 
positive  evidence  should  have  accumulated  by  this 
time  to  leave  no  doubt,  and  this  cannot  be  said  to 
be  true.  The  same  may  be  said  of  urotropin  and 
the  various  silver  salts  which  have  been  vaunted  so 
highly.  Upon  none  of  these  can  the  surgeon  depend 
with  any  distinct  hope  that  they  will  be  of  value. 
The  use  of  whisky  is  in  a  different  class.  Any  value 
it  may  have  depends  upon  the  fact  that  its  elements 
are  less  stable  than  normal  cell  protoplasm,  and  con- 
sequently there  is  some  hope  that  the  toxin  may  unite 
with  these  rather  than  cause  destruction  of  the  living 
cells.  There  may  be  some  truth  in  this.  The  trouble 
is  that  to  be  of  much  value  in  this  regard  there  should 
be  a  considerable  amount  in  the  blood,  and  the  excre- 
tion of  any  considerable  amount  would  be  injurious 
to  the  kidneys. 

In  this  connection  it  has  been  my  habit  to  give  these 
patients  who  are  seriously  ill  fully  peptonized  food 
per  rectum  if  they  cannot  take  it  by  mouth,  so  as 
to  introduce  into  the  blood  peptones,  less  stable  than 
normal  albumin  of  the  living  cells,  with  the  hope  that 
the  toxins  will  unite  with  the  less  stable  combinations 


DISCUSSION  OF  VARIOUS  PROCEDURES          367 

and  thus  protect  the  system.  This  can  do  no  harm, 
and  may  do  good. 

Related  to  this  we  have  the  use  of  normal  salt 
solution  or  plain  water  introduced  into  the  system 
per  rectum,  as  well  as  large  amounts  of  water  and 
fluids  by  mouth.  In  serious  cases  the  normal  salt 
may  be  given  subcutaneously.  It  is  my  belief  that  the 
introduction  of  large  amounts  of  fluid  with  the  idea 
of  diluting  and  eliminating  the  toxins  is  of  great 
value. 

Serum  and  Vaccine  Treatment. — We  have  not  as  yet 
developed  any  serum  or  vaccine  that  can  be  said  to 
be  of  definite  value  in  these  acute  cases.  The  field 
is  a  most  engaging  one,  and  many  attempts  have 
been  made  to  produce  an  antitoxin.  The  difficulties 
seem  to  be  almost  insuperable.  If  given  very  early 
it  might  have  some  effect,  since  some  of  the  sera, 
such  as  that  of  Aronsen,  have  some  bactericidal  in 
addition  to  its  antitoxic  and  opsonizing  effect.  Often 
the  toxemia  is  well  advanced,  and  such  an  immense 
amount  of  antitoxin  would  be  necessary  to  neutralize 
the  toxins  that  we  cannot  hope  to  inject  it,  and  the 
opsonizing  and  bactericidal  effects  are  insufficient. 
Moreover,  it  has  been  shown  many  times  that  the 
antitoxin  prepared  for  one  type  of  streptococcus 
will  have  no  effect  upon  the  toxins  generated  by  a 
second  type  of  streptococci.1 

Van  de  Velde  showed  that  the  leukocidin  produced 
by  one  staphylococcus  pyogenes  aureus  might  be 
almost  innocuous,  while  another  might  be  most 
virulent.  Denys,  Van  de  Velde,  Neisser,  and  Wech- 
berg  have  produced  antileukocidin,  but  it  must  be 
for  the  specific  organism. 

Therefore,  to  secure  the  best  results  a  serum  must 

1  Meakins,    Phagocytic   Immunity  in   Streptococcus    Infection,   Jour,   of 
Exper.  Med.,  xi,  815. 


368     THE  TREATMENT  OF  LYMPHATIC  INFECTIONS 

be  made  from  the  germ  producing  the  disease,  and 
this  is  manifestly  impossible,  since  the  time  is  too 
short.  In  attempts  to  obviate  this  difficulty  some 
have  made  their  antistreptococcus  serum  from  a 
combination  of  several  strains  of  streptococci,  i.  e., 
the  so-called  polyvalent  antistreptococcus  sera,  such 
as  those  of  Tavel,  Moser,  Menzer,  and  others,  while 
the  sera  of  Marmorek  and  others  is  monovalent, 
i.  e,,  made  from  one  strain.  Whether  these  sera  act 
in  a  bactericidal  or  antitoxic  manner  or  by  stimulating 
cellular  activity  is  a  subject  for  discussion,  but  at 
least  the  effect  is  inadequate.  It  is  possible  that  in 
the  more  chronic  types  vaccines  may  be  produced  that 
will  aid  somewhat.  In  this  connection  a  perusal  of 
Case  XXIV  should  be  of  interest.  In  this  case  almost 
all  of  these  methods  were  tried  without  avail. 

The  injection  and  use  of  elements  designed  to  in- 
crease leukocytosis  is  another  favorite  method  of  treat- 
ment. For  this  purpose  several  drugs  have  been  used, 
as,  for  instance,  protonuclein  and  nucleic  acid,  but 
without  definite  results.  His  has  recently  suggested 
the  injection  of  sterile  exudate,  secured  incident  to 
aseptic  injections  of  the  pleural  cavities  of  lower 
animals  with  aleuronat.  As  yet  this  has  not  secured 
a  trial. 

In  spite  of  the  lack  of  definite  results  by  any  of 
these  methods,  one  cannot  but  hope  that  the  future 
holds  some  promise  of  aid  from  these  studies.  The 
surgeon  should  always  have  in  mind  the  possibility 
of  value  from  the  sera,  watching  his  cases  closely 
for  a  favorable  opportunity;  but  as  the  case  now 
stands  it  is  my  personal  opinion  that  he  is  not  in 
position  to  promise  his  patients  any  distinct  curative 
action  in  the  more  acute  cases. 

Supportive  Measures. — Supportive  measures  in  the 
way  of  stimulants,  fresh  air,  good  food,  attention  to 


RESUME  369 

the  bowels,  and  proper  rest  should  not  be  neglected. 
The  fresh  air  and  sunlight,  especially  in  the  more 
chronic  cases,  is  of  distinct  value.  One  patient  suffer- 
ing from  such  a  chronic  infection,  which  defied  all 
manner  of  treatment,  was  transferred  to  an  open  air 
sun  room  where  he  lived  and  slept.  The  benefit  of  the 
change  was  evident  to  everyone.  (See  Case  XXIV.) 


Treatment  of  lymphatic  infection  is  based  upon  two 
principles—  conservatism  and  conservation.  In  general 
we  use  local  means  tending  to  wall  off  and  overcome 
infection,  combined  with  procedures  designed  to  sup- 
port the  system  and  increase  its  resisting  power. 

Local  Procedures:  Hot,  moist  dressings  applied 
voluminously  should  be  used  until  the  infection  is 
walled  off.  Boric  acid,  potassium,  permanganate, 
and  other  solutions  may  be  used.  Both  local  and  sys- 
temic rest  should  be  insisted  upon.  The  Bier  treat- 
ment is  of  some  value  in  preventing  rapid  extension 
of  the  infection.  Incisions  should  not  be  made  unless 
there  is  an  absolute  surety  that  there  is  an  accumula- 
tion of  pus. 

Systemic  treatment  such  as  quinine,  whisky,  uro- 
tropin,  and  silver  salts  all  have  advocates  and  in 
certain  instances  may  be  of  value,  although  probably 
in  the  majority  of  cases  they  will  be  found  to  be  of 
no  use. 

Peptonized  food  by  rectum  may  be  of  value.  Large 
amounts  of  normal  salt  or  water  is  probably  a  great 
aid  in  diluting  and  eliminating  the  toxin. 

Serum  and  vaccine  treatment  have  not  given  dis- 
tinct aid  in  these  cases. 

Supportive  measures  in  critical  cases  are  always  a 
great  benefit. 


CHAPTER  XXIV. 

THE  TREATMENT  OF  THE  COMPLICATIONS 
OF  LYMPHANGITIS. 

TENOSYNOVITIS. 

ATTENTION  has  been  drawn  to  the  frequency  of 
tenosynovitis  in  lymphatic  infections  beginning  in 
the  distal  phalanges  on  the  volar  surface.  In  the 
chapter  dealing  with  the  subject  of  tendon-sheath 
infections  (Chapter  XI),  a  complete  discussion  has 
been  given  which  should  enable  the  student  to  diag- 
nosticate the  presence  of  such  a  complication,  and 
rules  have  been  laid  down  for  the  treatment  that  has 
been  most  successful  in  my  hands.  There  only 
remains,  therefore,  a  discussion  of  such  general  prin- 
ciples as  pertain  to  lymphangitis  in  particular. 

If  the  patient  complains  of  great  pain  over  the  ten- 
don sheath  when  the  primary  puncture  has  been  upon 
the  volar  surface  of  the  finger,  even  though  the  pain 
has  not  extended  to  the  entire  finger,  one  should  be 
especially  on  his  guard,  and  the  moment  that  the 
tenderness  has  extended  from  the  site  of  the  infec- 
tion to  involve  the  distribution  of  the  subjacent 
tendon  sheath,  the  incision  should  be  made  exposing 
the  sheath.  If  one  delays  longer,  destruction  of  the 
synovial  covering  will  have  occurred,  in  which  case  the 
prognosis  for  function  is  much  more  grave.  It  is  my 
habit  to  make  lateral  incision  on  one  of  the  middle 
and  proximal  phalanges,  and  thus  secure  drainage, 
being  careful  not  to  produce  a  secondary  infection, 
and  also  using  care  to  cut  far  enough  toward  the  volar 


TENOSYNOVITIS  371 

surface  to  avoid  the  lateral  vessels  and  nerve  which 
run  up  the  sides  of  each  finger.  If  there  is  much 
destruction  of  the  synovial  covering,  parietal  and 
tendinous,  it  will  be  advisable  to  lengthen  the  incision 
upon  one  side  so  as  to  connect  the  two  phalangeal 
cuts,  thus  giving  free  drainage  but  preventing 
prolapse  of  the  tendon  because  of  the  lateral  site  of 
the  incision.  This  is  further  prevented  by  placing  a 
dorsal  splint  upon  the  finger  and  hand,  which  tends 
to  keep  the  finger  in  extension  and  thus  favor  reten- 
tion of  the  tendon  in  its  proper  place.  If  one  is  very 
prompt  in  the  incision,  so  that  no  destruction  has 
taken  place,  he  is  gratified  and  surprised  at  the  rapid 
recovery  he  secures.  Sometimes  it  is  entirely  well 
by  the  end  of  ten  days  or  two  weeks.  If  the  process 
has  lasted  some  time,  it  is  frequently  necessary  to 
incise  at  the  side  of  the  finger  over  the  lumbrical 
space  to  secure  drainage  of  the  loose  tissue  here  and 
in  the  web.  Care  should  be  taken  here  not  to  cut 
the  blood  supply.  If  there  is  doubt  as  to  the  side 
involved,  it  may  be  best  to  cut  down  upon  the  median 
surface  over  the  proximal  end  of  the  sheath  in  the 
palm  and  then  secure  drainage  from  either  side  through 
this  incision  by  inserting  an  artery  forceps  into  the 
loose  tissue  at  the  side  and  separating  the  blades  so 
as  to  give  free  exit  to  the  pus  (see  p.  260,  and  Figs. 
98  and  100).  If  vaseline  gauze  or  gutta-percha  drain- 
age is  inserted  in  the  early  cases,  it  can  be  removed 
the  next  day.  If  the  thumb  or  little  finger  is  the  source 
of  the  infection,  the  radial  or  ulnar  bursae  are  opened 
after  the  method  described  in  Chapter  XVI.  If  there 
is  no  tenderness  above  the  wrist  it  may  not  be  neces- 
sary to  make  the  lateral  incision  above  the  flexor 
surface  of  the  ulna  and  radius.  If  there  is  any  tender- 
ness, however,  or  swelling,  incisions  should  be  made 
at  once  and  drainage  instituted  (see  p.  265).  Before 


372  TREA  TMENT  OF  COM  PLICA  TIONS  OF  LYMPH  A  NGITIS 

any  incisions  are  made  the  Martin  elastic  bandage 
should  be  applied  to  the  arm,  and  following  the  opera- 
tion it  should  be  loosened  only  to  the  degree  neces- 
sary to  produce  a  marked  Bier's  hyperemia.  This 
helps  to  wash  the  toxins  out  of  the  tissue  adjacent  to 
the  wound,  and  also  prevents  the  rapid  absorption 
of  toxins,  a  fact  which  I  have  already  discussed. 
All  the  various  locations  of  pus  secondary  to  tendon- 
sheath  infections  and  the  proper  procedures  indicated 
in  their  treatment  have  been  discussed  in  Chapter 
XVI. 

SUBCUTANEOUS  ABSCESSES. 

Subcutaneous  abscesses  frequently  appear  upon  the 
dorsum.  As  soon  as  a  definite  redness  and  hardness 
have  appeared,  indicating  pus,  free  incisions  should 
be  made.  Simple  redness  and  edema  is  not  suffi- 
cient to  indicate  incision,  but  when  the  hardness  has 
been  added  free  incisions  under  the  same  precautions 
as  mentioned  above  should  be  made.  The  presence 
of  extensive  subcutaneous  destruction  of  the  connec- 
tive tissue  with  the  formation  of  a  slough  with  strepto- 
coccus pus  is  one  of  the  most  serious  complications. 
Incision  should  be  made  early,  in  several  places  upon 
the  dorsum,  so  as  to  give  perfect  drainage.  At  the 
risk  of  useless  repetition,  let  me  say  again  that  I  am 
speaking  of  the  indurated,  brawny,  dark  red  dorsum, 
characteristic  of  the  spreading  virulent  phlegmon,  not 
of  the  pinkish,  edematous,  pitting  dorsum.  Neither 
am  I  speaking  of  the  simple  staphylococcus  abscess. 
The  gravity  of  this  severe  type  has  long  been 
recognized.1 

1  Bauchet  thus  describes  how  they  were  considered  and  treated  by  Velpeau: 

"An  unconfined  phlegmon  is  one  of  the  most  serious  complications  of  a 

whitlow.    It  is  heralded  by  a  series  of  serious  symptoms  here  as  in  all  other 

parts,  by  a  considerable  swelling,  and  a  characteristic  dull,  yellowish  redness. 

"The  diffuse  phlegmon' is  undoubtedly  a  serious  matter  when  it  appears 


SUBCLAVICULAR  AND  SHOULDER  ABSCESSES    373 
PERIGLANDULAR  ABSCESSES. 

Periglandular  abscesses  occur  especially  on  the 
epitrochlear  and  axillary  regions.  These  are  not  so 
virulent  as  the  type  just  described,  and  a  more  con- 
servative course  may  be  pursued.  Since  they  start 
from  glandular  suppuration,  some  days  will  elapse 
before  they  become  evident.  The  surgeon  will  often 
be  in  doubt  for  a  day  or  two  as  to  whether  the  infec- 
tion may  not  be  a  simple  glandular  hyperplasia. 
The  waiting  period  is  not  without  advantage  to  the 
patient,  since  it  offers  an  opportunity  for  the  abscess 
to  become  walled  off,  and  thus  favors  the  prevention 
of  extension  when  it  is  opened. 

SUBCLAVICULAR  AND   SHOULDER  ABSCESSES. 

The  occurrence  of  such  an  abscess  will  of  course 
be  rare,  since  they  arise  in  the  course  of  the  lymphan- 
gitis extending  along  the  lymphatics  lying  in  the  pec- 
terodeltoid  groove,  having  its  origin  most  commonly 
in  the  middle  finger.  It  has  been  my  fortune  to  meet 
with  only  one  such  case,  and  this  began  in  the  index 
finger.  Dr.  J.  M.  Neff,  of  Spokane,  has  seen  and 

on  the  back  of  the  hand,  but  it  is  even  more  dangerous  when  it  invades  the 
forearm  and  arm. 

"The  first  symptoms  of  this  awful  complication  once  recognized,  one  must 
not  hesitate  to  have  recourse  to  the  most  drastic  therapeutic  measures;  anti- 
phlogistics,  local  and  general  baths,  purgatives,  opiates,  and  the  arm  placed 
in  an  elevated  position.  If  at  the  end  of  twenty-four  or  thirty-six  hours  the 
symptoms  do  not  mend,  and  if  the  disease  seems  stationary,  one  must  insist 
upon  the  compresses,  if  the  patient  has  been  able  to  stand  them,  after  generous 
applications  of  ointments  of  mercury.  If  the  compresses  increase  the  pain, 
one  may  profitably  resort  to  the  application  of  a  large  volatile  vesicatory, 
covering  all  the  diseased  parts.  This  means,  so  extolled  by  M.  Velpeau,  has 
and  always  will  render  good  service. 

"However,  if  the  general  symptoms  continue  to  grow  worse,  if  the  swelling 
increases,  the  moment  to  proceed  with  the  bistoury  has  come,  and  three  or 
four  long  deep  incisions  must  be  made.  This  is  the  only  road  to  recovery  left 
to  the  patient." 


374  TREA  TMENT  OF  COM  PLICA  TIONS  OF  L  YMPHA  NGITIS 

operated  upon  another  one,  in  which  the  origin  was 
in  the  middle  finger,  followed  in  three  days  by  a 
subclavicular  abscess,  which  was  opened,  and  this  in 
turn  was  followed  or  accompanied  by  a  synovitis  of 
a  knee-joint  of  a  serious  nature,  but  from  which  the 
patient  ultimately  recovered.  This  case  then  is  most 
interesting,  since  it  emphasizes  the  origin  of  these 
abscesses  and  also  serves  to  emphasize  what  I  have 
previously  called  attention  to,  and  that  is  the  seri- 
ousness and  frequency  of  systemic  involvement  from 
lymphangitis  originating  in  the  middle  finger. 

SYSTEMIC  COMPLICATIONS. 

These  must  be  met  as  they  arise  and  the  treat- 
ment based  upon  the  general  surgical  principles 
governing  septicema  and  pyemia.  The  metastatic 
abscesses  should  be  opened,  empyemas  drained,  pneu- 
monia, etc.,  guarded  against  with  every  possible  pre- 
caution. 

The  question  of  amputation  of  the  arm  in  these 
severe  cases  will  be  a  constant  one,  but  no  definite 
rules  can  be  laid  down.  One  will  constantly  feel  in 
the  early  cases  that  amputation  is  too  severe  for  the 
condition,  and  when  systemic  infection  has  begun 
it  will  be  considered  that  amputation  will  be  futile, 
so  that  the  indications  for  amputation  will  be  drawn 
between  narrow  lines.  In  exceptional  cases  some 
hope  may  be  offered  by  this  procedure,  as,  for  instance, 
in  a  spreading  phlegmon  or  in  a  malignant  edema. 

CHRONIC  INFECTIONS;  REPEATED  INFECTIONS. 

It  is  an  unfortunate  fact  that  one  infection  with 
a  streptococcus  does  not  immunize  the  patient;  at 
least,  if  it  does,  it  is  only  for  a  short  time.  Not  only 


CHRONIC  INFECTIONS;  REPEATED  INFECTIONS    375 

are  repeated  infections  possible,  but  one  infection 
seems  almost  to  favor  a  second  at  a  later  date.  This 
is  not  true  to  the  same  degree  with  the  staphylococcus, 
by  which  a  mild  degree  of  immunization  may  be 
secured.  This  is  demonstrated  by  the  raising  of  the 
opsonic  index  as  determined  by  the  Wright  method. 
The  streptococcus  particularly  not  only  may  not 
develop  immunization,  but  also  lacks  to  a  marked 
degree  the  power  in  many  cases  to  produce  antitoxins 
in  a  degree  sufficient  to  overcome  itself,  so  that  we 
often  see  cases  of  chronic  long-continued  infection 
which  undoubtedly  had  their  origin  in  a  streptococcus 
infection.  No  better  example  of  this  type  of  infection 
could  be  cited  than  that  of  a  case  I  saw  with  Dr. 
Oleson,  of  Lombard,  111.  It  is  true  that  another 
factor  came  into  this  case,  namely,  that  the  infection 
had  possibly  come  from  organisms  which  had  passed 
through  a  lower  animal  which  we  know  may  change 
the  virulence  in  many  ways.  The  case,  however, 
is  worth  a  careful  perusal,  since  it  was  so  carefully 
and  conscientiously  treated  by  Dr.  Oleson  by  every 
known  scientific  method,  and  yet  it  resisted  treat- 
ment for  over  two  years,  the  patient  apparently  not 
having  the  slightest  ability  to  develop  antitoxins. 
He  has  now  completely  recovered. 

Dr.  Oleson  has  already  reported  the  case,  and  I 
herewith  abbreviate  his  report: 

CASE  XXIV. — "On  June  15,  1906,  over  three  years 
ago,  the  patient  removed  a  wart  from  the  index  finger 
of  his  right  hand,  leaving  an  opening  in  the  subcutaneous 
tissue  which  did  not  readily  close.  While  this  condition 
existed  he  received  orders  to  care  for  some  sick  calves, 
afflicted  with  a  disease  which  caused  dyspnea,  with 
considerable  salivation.  In  giving  them  medicine  it 
was  necessary  for  him  to  introduce  his  right  hand  into 
their  mouths,  with  the  natural  consequence  that  it  became 
covered  with  their  slobbery  saliva.  In  a  few  days  he 


376  TREA  TMENT  OF  COM  PLICA  TIONS  OF  LYMPHANGITIS 

sickened  and  called  in  Dr.  William  Dillon,  of  Urbana, 
who  reports  under  date  of  August  18,  1906,  substantially 
as  follows: 

"'In  regard  to  Mr.  J.'s  illness,  I  was  called  to  his  room 
about  9  P.M.,  June  27  (1906).  I  found  him  lying  down, 
with  perspiration  in  large  drops  over  his  face,  pulse  full 
and  rapid,  temperature  about  103°  F.  Pain  about  axilla. 
Axillary  glands  indurated  and  enlarged.  There  was  a 
small  unhealed  place  in  the  centre  of  a  spot  on  one  of  his 
right  fingers,  from  which  I  could  press  out  a  little  serum, 
but  which  had  no  soreness.  I  ordered  fomentations 
during  the  night,  with  magnesia  sulphate  internally.  The 
following  morning  there  was  less  pain,  but  more  fever, 
and  I  had  him  removed  to  a  hospital,  where  the  treatment 
was  continued.  The  glands  returned  to  their  normal 
size  so  far  as  could  be  detected,  but  fever  and  sweating 
continued.  About  the  third  day  in  the  hospital  painful 
tympanites  developed,  also  swelling  along  the  general 
direction  of  the  pectoralis  tendon  from  a  little  below  the 
arm-pit  to  near  the  eleventh  rib.  This  was  the  first  appearance 
of  localization.  I  called  in  Dr.  Newcomb,  who  aseptically 
incised  the  tissues  down  through  the  deep  fascia.  A 
little  serum  escaped.  About  July  22  the  second  incision 
was  made  and  the  entire  cavity  washed  out  with  bichloride 
and  dressed  with  dry  dressings.  Now  the  patient  rapidly 
improved  and  the  abscess  walls  united  so  that  when 
irrigated  the  fluid  would  extend  but  a  short  distance  in 
any  direction.  The  pus  by  July  30  had  almost  ceased. 
Temperature  normal,  pulse  normal,  patient  bright,  no 
sweating." 

Dr.  Oleson  here  continues: 

"I  first  saw  the  patient  on  August  10,  1906.  On  enter- 
ing my  office  a  limitation  of  motion  in  the  right  shoulder 
and  a  marked  cervical  scoliosis  was  evident.  He  was 
pale,  anemic;  pulse,  106;  temperature,  98°  F.  At  the 
anterior  margin  of  the  right  axilla,  along  the  border  of 
the  pectoralis  major,  appeared  a  long  scar,  presenting 
at  its  upper  end  a  small  orifice  discharging  a  thin  blue- 
green  serum.  A  second  opening  existed  to  the  axillary 
side  of  the  scar,  about  an  inch  below  the  first  sinus.  No 
swelling,  some  redness,  tenderness  slight,  shoulder-joint 
motion  limited,  evidently  from  scar  contraction.  A 


CHRONIC  INFECTIONS;  REPEATED  INFECTIONS  377 

flexible  sterilized  probe  introduced  into  the  sinus  with 
strict  asepsis  passed  under  the  clavicle  for  some  distance 
toward  the  vertebrae,  so  that  the  general  clinical  picture 
simulated  a  cervical  Pott's.  But  a  few  days'  study  sat- 
isfied me  that  there  was  no  vertebral  disease,  nor  could 
I  find  evidence  of  any  shoulder- joint  trouble. 

"He  passed  into  the  hands  of  a  neighboring  sectarian 
practitioner,  and  after  some  weeks  of  unimprovement 
entered  a  homeopathic  hospital  in  this  city.  Here  the 
gradually  enlarging  ulcer,  which  appeared  at  the  site  of 
the  sinus  and  slowly  spread  downward  along  the  thoracic 
wall  in  the  direction  of  the  original  incision,  was  curetted, 
and  the  patient  received  considerable  x-ray  treatment, 
with  a  steady  failure  of  his  vital  forces  until  the  latter 
part  of  March,  1907,  some  nine  months  after  the  oirginal 
infection,  when,  on  the  suggestion  of  the  hospital  author- 
ities, he  was  taken  from  the  institution  to  end  his  days 
among  his  friends.  Here  I  saw  him  on  March  28,  1907, 
since  which  time  he  has  been  continuously  under  my  care. 
He  presented  then  the  typical  picture  of  advanced  chronic 
sepsis.  He  was  thin,  haggard,  with  a  marked  Hippo- 
cratic  facies,  scoliosis  more  evident,  temperature  running 
a  classical  hectic  curve  (morning  remissions  to  98°  F., 
evening  readings  varying  around  102°  F.),  then  con- 
stantly between  120°  and  130°,  having  the  appearance 
of  impending  death.  Locally  the  margins  of  the  sinus 
had  broken  down  to  form  along  the  thoracic  wall  a  deep 
ragged  ulcer  as  large  as  the  palm  of  one's  hand  with 
sinuses  radiating  upward,  forward,  and  downward,  honey- 
combing the  tissues  in  the  pectoral  region,  while  over 
the  third  and  fourth  right  costochondral  junctions  ap- 
peared bluish-red  depressed  areas,  evidently  marking 
points  at  which  pus  was  about  to  appear.  The  former 
bluish-green  discharge  was  now  almost  colorless,  very 
profuse,  and  of  a  thin  serous  nature,  soaking  large  gauze 
dressings  daily. 

"On  April  6,  1907,  under  chloroform  anesthesia  by 
Dr.  Pickard,  with  Dr.  W.  F.  Scott  assisting  me,  I  removed 
inflamed  periosteum  and  perichondrium,  with  subjacent 
necrotic  tissue  at  the  points  indicated  by  the  discolored 
skin,  curetting  from  all  accessible  places  the  various 
sinuses,  scraping  out  large  quantities  of  soft,  pale,  pulpy, 


378  TREA  TMENT  OF  COM  PLICA  TIONS  OF  LYMPHANGITIS 

friable  granulations,  with  free  hemorrhage  easily  checked 
by  pressure.  The  patient  was  put  to  bed  in  an  exhausted 
condition,  while  my  consultants  cheerfully  foretold  an 
early  lethal  termination. 

"On  May  6,  1907,  I  performed  a  second  similar  opera- 
tion, attacking  new  fresh  necrotic  areas  over  the  second 
and  fifth  costochondral  junctions.  The  result  of  these 
two  operations  was  a  considerable  improvement  in  the 
pulse  curve,  which  now  rarely  went  over  no,  while  the 
temperature  did  not  pass  above  101°,  with  no  loca  change 
except  the  healing  of  one  sinus  which  had  invaded  the 
tissues  from  the  lower  margin  of  the  ulcer. 

"On  July  6,  1907,  I  performed  what  was  intended  for 
a  radical  operation,  by  making  a  deep  curved  incision 
from  the  lower  border  of  the  ulcer,  anteriorly  to  the 
sternum,  separating  the  entire  pectoral  flap  of  muscles, 
reflecting  them  back  over  the  shoulder  and  exposing  this 
region  for  general  curettage. 

"After  thorough  scraping  of  all  other  lesions  the  flap 
of  muscle  was  sutured  back  into  place.  The  patient  did 
not  react  well,  it  being  several  days  before  he  ceased 
vomiting,  and  the  general  immediate  result  of  this  inter- 
vention was  the  actual  spread  of  the  infection,  as  it  fol- 
lowed each  suture  and  needle  puncture  into  new  regions, 
reaching  around  alsointo  the  intermuscular  septaand  subcu- 
taneous tissue  of  the  back,  a  region  previously  uninvaded. 
Various  abscesses  were  opened  during  the  next  month. 

"During  all  this  time  the  wound  had  been  dressed  by 
daily  irrigation  through  drainage  tubes  or  along  the 
sinus  tracts.  All  sorts  of  fluids  had  been  used — normal 
saline,  plain  sterilized  water,  iodine  water,  hydrogen 
peroxide,  pure  and  in  solutions  of  varying  strengths, 
bichloride  and  phenol  dilutions,  with  no  appreciable 
improvement.  On  September  2,  1907,  I  made  a  radical 
change;  permanently  abandoning  all  forms  of  irrigations, 
and  substituting  plain,  dry,  sterile  dressings,  with  immedi- 
ate marked  improvement  in  the  general  condition.  The 
temperature  fell  to  99°  and  remained  there,  while  the  pulse 
varied  between  90  and  100.  There  had  been  nervous 
digestive  disturbances,  so  that  any  unwelcome  suggestion, 
e.  g.,  the  discussion  of  an  anesthetic  or  the  odor  of  ether, 
etc.,  would  cause  a  prompt  and  thorough  emesis.  Yet 


CHRONIC  INFECTIONS;  REPEATED  INFECTIONS     379 

he  had  gained  10  pounds  in  bodily  weight  in  five  months, 
but  with  the  cessation  of  irrigation,  the  digestive  derange- 
ment ceased,  he  took  and  retained  large  amounts  of  food, 
with  cod-liver  oil,  sevetol,  etc.,  so  that  in  the  next  five 
months  he  gained  26  pounds,  with  corresponding  physical 
improvement.  By  the  middle  of  January,  1908,  he  was 
strong,  robust,  healthy  appearing,  but  with  absolutely 
no  improvement  whatever  in  the  local  lesion,  which 
remained  stationary,  discharging  daily  large  quantities 
of  seropus,  necessitating  copious  aseptic  dressings. 

"At  about  this  time  Dr.  Emil  Beck  announced  the 
result  of  his  work  in  the  treatment  of  certain  unhealed 
sinuses  by  the  bismuth  paste  method.  Injections  were 
given  January  22  and  28,  1908,  with  no  special  result 
except  that  the  patient's  weight  fell  off  a  little.  In  order 
to  give  the  paste  a  little  better  chance,  I  decided  to 
curette  the  granulations  from  the  sinuses  again,  and  then 
to  make  a  third  injection.  This  I  did  on  February  10, 
1908,  and  on  the  morning  of  February  n,  I  found  my 
patient  with  a  pulse  of  140;  temperature,  102°;  rusty 
sputum  and  consolidation  of  the  left  lower  lobe. 
A  typical  crisis  occurred  on  the  seventh  day,  with  uncom- 
plicated convalescence.  One  peculiar  phenomenon  pre- 
sented itself  on  the  third  morning  of  the  seizure,  when 
the  patient  suddenly  expectorated  a  single  mouthful 
of  pure  pus,  of  which  the  anatomical  origin  was  never 
satisfactorily  located. 

"On  February  26,  1908,  he  returned  to  his  home, 
having  lost  17  pounds,  which  he  proceeded  to  regain. 
At  this  time,  through  the  courtesy  of  Prof.  Ormsby,  I 
secured  from  the  research  laboratory  of  Parke,  Davis 
&  Co.,  a  supply  of  staphylococcus  vaccine,  varying  doses 
being  injected  on  March  14,  and  for  a  month  afterward, 
without  effect.  Thorough  search  was  now  made  by  Prof. 
Ormsby  for  evidences  of  blastomycosis,  actinomycosis, 
and  tuberculosis,  with  negative  results.  Prof.  Hektoen 
now  generously  placed  at  my  disposal  his  laboratory 
facilities,  and  his  assistant,  Dr.  D.  J.  Davis,  readily  iso- 
lated from  the  pus  a  streptococcus  which  grew  abund- 
antly in  almost  pure  cultures,  but  presented  no  identifying 
morphological  characteristics.  The  patient's  opsonic  index 
to  this  organism  was  subnormal. 


380  TREA  TMENT  OF  COM  PLICA  TIONS  OF  LYMPHANGITIS 

"On  April  16,  1908,  I  injected  the  dead  bodies  of 
500,000,000  autogenous  cocci  obliquely  into  the  subcuta- 
neous tissue  of  the  right  thigh.  In  two  days  an  indura- 
tion appeared  at  the  site  of  injection.  Twelve  days  from 
date  of  puncture  fluctuation  was  evident  at  this  point. 
On  May  6,  twenty  days  from  the  injection,  the  skin  here 
grew  purplish.  Two  days  afterward,  on  May  8,  under 
aseptic  precautions,  I  aspirated  some  of  the  contents  of  the 
swelling,  which,  on  examination  by  Dr.  Davis,  proved  to 
be  sterile,  chemical  pus.  On  May  15,  twenty-nine  days 
after  injection,  the  skin  finally  broke  down  and  the  con- 
tents escaped,  leaving  a  superficial  ulcerated  area,  which 
slowly  cicatrized  across  from  the  margins,  ultimately  heal- 
ing on  July  3,  1908,  seventy-eight  days  after  the  date 
of  injection. 

"The  history  is  that  of  each  inoculation  made  obliquely, 
leaving  the  vaccine  in  the  subcutaneous  tissue.  As  time 
went  on  I  lessened  the  dose  to  250,000,000,  60,000,000, 
10,000,000,  and  each  one  caused  the  breaking  down  of 
connective  tissue,  the  formation  of  sterile  chemical  pus, 
the  death  of  the  overlying  skin  from  starvation — an 
open  ulcer — slow  healing,  so  that  we  finally  had  an 
absolute  clinical  demonstration  of  the  method  of  local 
spread  of  this  coccus,  namely,  by  the  secretion  of  toxins, 
which  by  their  chemical  action  on  the  connective  tissue — 
not  skin,  not  muscles,  but  subcutaneous  tissue,  fasciae, 
septa,  etc. — cause  this  to  gradually  die  and  melt  away, 
destroying  the  bloodvessels  which  run  in  its  meshes,  and 
so  bringing  about  the  death  of  overlying  skin  or  under- 
lying bone,  not  by  attacking  these  structures  themselves, 
but  by  cutting  off  their  nourishment. 

"To  prove  this  I  then  proceeded  to  inject  the  same 
doses  of  dead  cocci  deeply  in  the  muscles  themselves, 
beginning  with  10,000,000  and  steadily  increasing  the 
quantity  until,  on  August  29,  1908,  I  gave  him  300,000,000 
— and  not  once  was  there  the  least  reaction,  local  or 
general,  to  a  single  intramuscular  injection,  while  every 
one  of  the  oblique  subcutaneous  injections  of  the  same 
cultures,  with  identical  aseptic  precautions,  produced  local 
necrosis. 

"During  this  period,  while  we  were  endeavoring  to 
do  something  to  help  the  patient  by  means  of  specific 


CHRONIC  INFECTIONS;  REPEATED  INFECTIONS    381 

vaccine,  his  general  condition  failed  slightly.  He  lost 
about  8  pounds  in  weight,  and  there  was  a  slow  spread- 
ing by  undermining  the  skin  around  the  affected  area, 
so  that  at  the  end  of  this  time,  when  this  method  was 
abandoned,  the  area  involved  reached  its  maximum, 
covering  the  right  side  of  the  body  from  the  sternum 
into  the  middle  of  the  right  half  of  the  back  and  extend- 
ing from  a  point  above  the  clavicle  down  beyond  the 
costal  margin — a  stretch  of  29  cm.  in  each  diameter. 
I  now  decided  to  expose  the  affected  region  thoroughly, 
and  on  September  15,  1908,  I  curetted  again  all  sinuses 
and  completely  excised  all  undermined  skin.  At  last  this 
was  followed  by  actual  healing. 

"For  some  time  I  had  been  anxious  to  give  my  patient 
the  benefit  of  sunshine  in  direct  application  to  the  wound 
surfaces,  but  no  practicable  method  presented  itself  to  me 
on  account  of  the  large  area  to  be  covered  and  the  very 
free  discharge.  Fortunately,  on  November  28,  1908, 
Dr.  Allen  B.  Kanavel  saw  him  and  suggested  a  home- 
made wire  cage.  This  crude  appliance  was  applied  on 
December  3,  and  proved  to  be  the  one  missing  link  in 
the  chain  to  drag  the  patient  back  to  health.  The  wire 
cage  was  enveloped  with  sterile  gauze,  and  so  enfolded 
and  protected,  my  patient  has  spent  the  last  ten  months 
basking  in  the  sunlight,  with  slow  but  steady  healing  of 
the  local  lesions  in  all  spots  the  sun's  direct  rays  could 
reach.  The  range  of  pulse  is  in  the  sixties,  the  tempera- 
ture normal,  and  the  general  condition  most  excellent." 

The  history  of  this  patient  serves  to  emphasize 
that  in  such  cases  the  general  hygienic  rules  are  of 
more  value  than  any  special  procedures.  This  would 
include  outdoor  life  and  nourishing  food,  combined 
with  the  least  possible  local  treatment  of  the  infected 
areas.  The  -futility  of  vaccine  treatment  was  also 
emphasized. 


382  TREA  TMENT  OF  COM  PLICA  TIONS  OF  LYMPHANGITIS 


Tenosynovitis  should  be  treated  here,  when  it  ap- 
pears, as  elsewhere.  Description  of  the  technique  will 
be  found  in  the  chapters  dealing  with  that  subject. 

Subcutaneous  abscesses  which  appear  upon  the 
dorsum  should  be  opened  freely  but  simple  redness 
and  edema  do  not  indicate  pus  and  an  incision  should 
not  be  made. 

In  phlegmonous  lymphangitis  extensive  incision 
should  be  made  upon  the  dorsum. 

Periglandular  abscesses  should  be  opened  when 
they  appear.  One  should  be  conservative  and  not 
make  incision  too  early. 

Systemic  infection  should  be  treated  upon  the  same 
general  principles  as  septicemia  and  pyemia. 

Chronic  infections  and  repeated  infections  are  prob- 
ably better  treated  by  general  supportive  treatment, 
such  as  outdoor  life,  nourishing  foods,  etc.,  although 
in  certain  cases  vaccines  have  been  found  to  be  of 
value. 


SECTION   IV. 
ALLIED    INFECTIONS. 


CHAPTER  XXV. 

ERYSIPELAS,   ERYSIPELOID,  GAS-BACILLUS 
INFECTION,   ANTHRAX. 

ERYSIPELAS. 

ERYSIPELAS  may  appear  in  two  types :  first  an  uncom- 
plicated cutaneous  lymphangitis  corresponding  to  the 
picture  seen  upon  the  face,  and  second,  as  a  cutaneous 
lymphangitis,  complicated  with  a  subcutaneous  lym- 
phangitis. This  latter  type  is  more  common  in  the 
hand.  The  former,  the  rarer  type,  is  that  of  the 
typical  erysipelas  as  seen  upon  the  face  with  the 
brawny  induration  confined  to  the  skin  and  outlined 
by  a  distinct  border.  The  deep  purple-red  skin  may 
have  blebs  upon  it.  The  second  type  is  the  accom- 
paniment of  the  severe  subcutaneous  lymphangitis, 
and  has  been  discussed  on  pages  341  and  372. 

The  treatment  of  erysipelas  proper  is  clearly  that 
of  a  lymphangitis  which  also  has  been  discussed  (see 
pp.  361  and  366).  No  special  applications,  such  as 
carbolic  acid,  ichthyol,  salicylic  acid,  can  be  considered 
to  be  of  special  value.  In  the  superficial  type  the 
usual  hot,  moist  dressings  may  be  used;  the  treatment 
of  the  severer  types  referred  to,  which  are  often  called 
gangrenous  erysipelas  or  gangrenous  cellulitis  by 
surgeons,  has  been  discussed  on  page  372. 


384  ERYSIPELAS,  ERYSIPELOID,  ANTHRAX 

ERYSIPELOID. 

This  is  a  condition  seen  most  commonly  upon  the 
fingers  and  which  may  be  mistaken  for  true  erysipelas. 
The  earlier  writers  have  described  it  under  the  title 
of  chronic  erysipelas,  or  erythema  migrans.  Rosen- 
bach  designated  the  condition  erysipeloid,  a  name 
which  has  been  accepted  by  the  profession. 

It  commonly  has  its  origin  in  some  slight  wound, 
and  is  most  often  seen  in  those  handling  fish  and 
oysters  or  cheese  and  herring.  Therefore,  it  is  found 
among  fishermen,  butchers,  cooks,  etc.  Gilchrist 
has  described  his  findings  in  over  300  cases  which 
originated  in  crab  bites.  He  thought  the  condition 
was  due  to  a  ferment  injected  by  the  crab  bite,  and 
not  to  a  special  organism.  Rosenbach  described  a 
cladothrix-like  organism  as  the  cause,  and  this  finding 
was  later  confirmed  by  Ohlemann.  It  is  an  irregular 
round  organism,  developing  into  threads  in  old  cul- 
tures. Pathologically  one  finds  an  invasion  of  the 
corium  with  polynuclear  leukocytes  and  a  massing 
of  lymphoid  cells  about  the  bloodvessels. 

SYMPTOMS. — Following  a  slight  injury,  generally  upon 
the  fingers,  the  skin  becomes  swollen,  painful,  and 
of  a  deep  bluish  color.  There  is  some  local  burning 
and  itching,  but  no  fever  or  any  general  reaction. 
The  infection  extends  gradually  with  a  sharp  line  of 
demarcation  up  the  finger  into  the  hand  rarely  as 
high  as  the  middle,  but  it  may  involve  the  adjacent 
fingers.  As  it  extends,  the  older  area  becomes  pale. 
A  lymphangitis  of  a  very  resistant  type  may  develop. 
There  are  no  papules,  vesicles,  or  suppuration.  The 
disease  lasts  from  one  to  four  weeks,  varying  with 
the  treatment. 

TREATMENT. — Lexer  advises  immobilization  by  a 
splint  for  from  two  to  four  days,  accompanied  by 


GAS-BACILLUS  INFECTION  385 

applications  of  vaseline.  If  movement  begins  too 
early,  the  trouble  will  reappear.  Others  recommend 
25  per  cent,  salicylic  acid  ointment  followed  by  a 
bland  oil. 

GAS-BACILLUS  INFECTION. 

Under  this  title  many  conditions  are  included  which 
have  in  past  years  been  described  by  many  titles, 
such  as  gaseous  phlegmon,  emphysematous  gangrene, 
malignant  edema,  etc.  It  is  probable  that  there  are 
at  least  two  distinct  types  here  included,  if  not  more: 
namely,  infection  by  the. bacillus  of  malignant  edema 
and  that  by  the  Bacillus  aerogenes  capsulatus.  Other 
bacteria  may  produce  gas,  and  thus  come  under  this 
classification. 

While  we  may  thus  separate  them  etiologically, 
clinically  we  must  consider  them  as  one,  since  we  can- 
not be  certain  when  making  smears  at  the  operation 
with  which  type  we  are  dealing.  We  are  wont  to  say 
that  the  more  serious  type  is  probably  due  to  the 
bacillus  of  malignant  edema,  and  the  milder  type  to 
the  Bacillus  aerogenes  capsulatus.  We  cannot  be 
certain  of  this,  however,  and  for  the  purpose  of  treat- 
ment must  divide  them  into  fulminating  and  subacute, 
and  base  our  treatment  upon  this  without  regard  to 
the  organism  present. 

The  accompanying  table,  which  may  be  found  of  aid 
in  differentiating  the  various  organisms  obtained  by 
smear  or  culture  in  these  cases,  was  prepared  for  me 
by  Dr.  W.  H.  Buhlig.  It  is  designed  to  differentiate 
not  alone  the  virulent  organisms,  but  also  to  separate 
these  from  the  non-pathogenic  organisms  with  which 
they  may  be  confused. 


386 


ERYSIPELAS,  ERYSIPELOID,  ANTHRAX 


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GAS-BACILLUS  INFECTION  387 

The  condition  is  characterized  pathologically  by  a 
rapidly  spreading  inflammation  associated  with  the 
formation  of  gas,  the  presence  of  which  is  denoted- 
by  the  crepitation  found  on  palpation,  characteristic 
of  emphysema  elsewhere.  In  the  milder  cases,  locally, 
one  finds  a  moderate  degree  of  serum  between  the 
muscular  bodies  and  in  the  subcutaneous  tissue  asso- 
ciated with  gas.  Systemically,  one  finds  the  changes 
of  a  moderate  toxemia.  In  the  severe  cases  we  find 
a  diffuse,  watery,  semibody  edema  of  marked  degree, 
going  on  even  to  necrosis  of  tissue  with  gas  bubbles 
throughout.  There  is  an  absence  of  phagocytosis. 
Gas  bubbles  may  be  found  disseminated  in  the  blood- 
stream. An  excessive  amount  of  gas  speaks  for  an 
infection  by  the  Bacillus  aerogenes  capsulatus  rather 
than  one  by  the  bacillus  of  malignant  edema.  The. 
finding  of  a  mixed  infection  with  streptococci  and 
staphylococci  is  not  uncommon. 

The  infection  may  begin  with  the  slightest  wound, 
but  more  often  it  is  found  with  severe  injuries  in  which 
dirt  has  been  ground  into  the  tissues.  It  has  been  my 
fortune  to  see  three  cases  in  the  arm,  two  of  which 
began  from  very  insignificant  injuries,  and  the  third 
followed  a  compound  fracture  of  a  finger. 

In  the  milder  cases  the  systemic  evidences  of  toxemia 
are  not  marked.  The  local  swelling  is  frequently 
very  great,  however,  and  one  elicits  the  sense  of  crepi- 
tation under  the  palpating  finger.  The  history  is  that 
of  a  wound  received  twenty-four  to  forty-eight  hours 
before.  The  arm  is  reddened  and  the  swelling 
increases  rapidly.  Upon  incision,  free  fluid,  non- 
bloody,  is  seen,  and  from  between  the  blanched  mus- 
cles the  gas-laden  serum  can  be  evacuated.  Following 
free  opening  the  extension  stops. 

In  the  severer  type  the  evidences  of  systemic 
intoxication  are  marked.  The  restless  roving  eye, 


388  ERYSIPELAS,  ERYSIPELOW,  ANTHRAX 

the  nervous  movements  of  the  body  and  hands,  the 
parched  tongue,  cold,  perspiring  brow,  scanty,  high- 
colored  urine,  and  running  pulse  are  evident. 

Locally  the  evidences  of  severe  infection  are  marked. 
While  the  gaseous  crepitation  may  not  be  any  more 
marked,  and,  indeed,  it  is  often  less  so,  yet  to  it  is 
added  the  livid  or  blackish  color  suggestive  of  impend- 
ing gangrene;  the  epidermis  may  be  raised  in  blebs 
filled  with  a  dark,  bloody  fluid,  the  skin  is  hard,  and 
incision  evacuates  a  reddish  or  brownish  fluid,  foul- 
smelling,  and,  as  a  rule,  containing  gas.  The  muscles 
may  begin  to  show  the  evidence  of  oncoming  gangrene, 
while  the  subcutaneous  and  intermuscular  tissue  may 
already  have  become  necrotic.  The  process  con- 
tinues to  spread  rapidly  in  spite  of  the  incisions.  The 
arm  becomes  gangrenous  and  the  patient  rapidly 
succumbs  to  the  toxemia,  sometimes  in  from  four  to 
five  days. 

The  prognosis  depends  upon  the  type  and  the 
promptness  of  treatment.  As  our  experience  grows 
it  is  probable  that  we  will  be  enabled  to  apply  the 
proper  treatment  earlier,  and  in  certain  cases  demand 
amputation  more  promptly,  and  thus  reduce  the 
mortality,  which  now  varies  from  30  to  55  per  cent, 
according  to  various  authorities.  Personally,  of  my 
three  cases  one  recovered  and  two  died.  One  of  these 
two  was  seen  too  late  for  any  hope  of  relief. 

If  we  could  but  differentiate  the  types,  clear  indi- 
cations for  treatment  could  be  placed.  Unfortunately, 
this  is  not  the  case.  The  milder  type  of  infection  due 
to  the  Bacillus  aerogenes  capsulatus  can  often  be 
cured  by  wide  incisions  draining  every  focus.  This 
includes  separating  the  muscular  masses  if  necessary, 
washing  out  the  areas  with  peroxide  of  hydrogen  or 
oxygenated  water,  and  inserting  gauze  drainage  to 
prevent  the  collapse  of  the  openings  and  thus  giving 


GAS-BACILLUS  INFECTION  389 

the  anaerobic  bacteria  an  opportunity  for  further 
development.  The  cutaneous  incisions  should  be 
extensive  and  left  unsutured.  If  under  this  treatment 
there  is  any  tendency  to  spread  in  the  next  twelve 
hours,  amputation  should  be  advised.  The  same 
advice  should  be  given  in  the  more  virulent  type  as 
shown  by  the  local  and  systemic  reaction.  Here  no 
time  should  be  wasted  in  palliative  measures,  for  the 
patient  rapidly  passes  into  the  stage  of  systemic  infec- 
tion or  toxemia,  from  which  he  will  not  recover  even 
with  amputation.  One  may  say,  therefore,  that 
amputation  should  be  performed  in  case  of  doubt. 
It  should  be  done  well  proximal  to  the  infection,  so 
as  to  make  incisions  in  healthy  tissue,  and  the  stump 
should  be  left  open  for  secondary  suture  after  we  are 
certain  that  the  process  is  under  control. 

My  own  experience  in  three  cases  bears  out  these 
statements.  In  the  first  case  seen,  amputation  was 
performed  at  once  and  the  patient  recovered  promptly. 
The  gaseous  infection  had  spread  well  into  the  arm. 
The  amputation  was  performed  at  the  upper  third 
of  the  humerus.  In  the  second  case  seen  in  consulta- 
tion, wide  incisions  were  made  which  were  further 
increased  upon  the  next  day.  The  patient  was  not 
seen  by  me  subsequent  to  the  first  day.  I  am  informed, 
however,  that  the  gaseous  infections  subsided,  and 
a  secondary  infection  began  from  which  the  patient 
succumbed  at  the  end  of  three  weeks.  The  third 
case  seen  by  me  was  one  in  which  the  patient  had 
suffered  a  slight  abrasion  of  the  middle  finger  of  the 
left  hand.  I  saw  him  at  the  end  of  the  fifth  day,  when 
the  systemic  condition  showred  the  patient  to  be 
suffering  from  a  marked  toxemia.  The  whole  arm 
has  a  bluish-black  color,  is  swollen,  and  covered  by 
blebs.  The  arm  was  amputated  by  an  able  surgeon 
at  once,  but  the  patient  succumbed  from  his  toxemia 
within  a  few  hours. 


390          ERYSIPELAS,  ERYSIPELOID,  ANTHRAX 

ANTHRAX. 

Anthrax  is  not  common  in  the  United  States, 
although  sporadically  it  may  appear  in  various  sections. 
The  frequency  of  lesions  upon  the  hand  and  arm  is 
given  by  Koch  in  a  series  of  923  cases  as  40  per  cent. 
Keen  has  described  a  typical  case  in  the  Annals  of 
Surgery  of  August,  1905.  Personally,  my  experience 
is  limited  to  one  case  seen  during  my  interneship  at 
the  Cook  County  Hospital.  The  description  of  the 
condition  which  I  append  is  modified  from  that  given 
in  Frazier's  excellent  description  of  the  disease.  No 
attention,  of  course,  is  here  given  to  the  pulmonary 
and  intestinal  types.  When  the  disease  is  implanted 
upon  the  hand  or  forearm  of  those  having  to  deal 
with  hides  and  other  sources  of  infection,  we  note  an 
elevated  pustule,  5  mm.  to  several  centimeters  in 
diameter,  with  a  depressed  central  scab.  The  corium 
and  papillary  body  become  infiltrated  with  a  sero- 
cellular  exudate  and  with  bacilli.  The  perivascular  and 
connective-tissue  spaces  become  filled  with  leukocytes, 
and  the  pressure  of  this  serous  and  cellular  infiltrate, 
together  with  the  toxins  of  the  bacteria,  cause 
the  central  coagulation  necrosis,  though  suppuration 
does  not  occur  unless  there  is  a  mixed  infection. 
When  the  serocellular  exudate  extends  upward  to 
the  superficial  epithelium,  it  elevates  the  latter  and 
produces  the  typical  vesiculation.  In  the  edematous 
variety  the  swelling  is  due  to  the  diffuse  serocellular 
infiltrate  and  to  the  effect  of  the  bacteria  blocking 
or  inducing  coagulation  in  the  capillary  vessels. 

The  lesion  may  be  transferred  to  other  parts  of 
the  arm  or  body,  especially  the  face,  by  scratching 
the  lesion  and  then  the  secondarily  infected  part. 
Wherever  the  lesion  occurs  we  note  that  from  a  few 
hours  to  some  days  after  the  inoculation  some  itching 


ANTHRAX  391 

and  burning  are  felt,  and  upon  inspection  a  small 
papule  with  a  central  bluish  point  is  seen.  A  few 
hours  later  the  papule  becomes  vesiculated,  contains 
a  brownish,  sanguineous  fluid,  and  may  be  scratched 
off  by  the  patient.  The  surrounding  tissues  become 
red,  indurated,  and  puffy,  and  later  purplish  and 
gangrenous  in  appearance,  although  there  may  be 
no  indication  of  suppuration.  Pain  now  ceases,  and 
beyond  malaise,  nausea,  slight  fever,  and  muscular 
or  joint  pains,  there  may  be  no  other  constitutional 
effect.  A  vesicular  areola  limited  in  extent  is  soon 
observed  about  the  pustule,  containing  serohemor- 
rhagic  fluid;  the  pustule  may  undergo  necrosis,  the 
area  of  necrosis  rarely  exceeding  3  cm.  in  diameter. 
In  about  ten  days,  in  favorable  cases,  a  line  of  demar- 
cation forms  about  the  eschar,  which  "floats  off," 
leaving  a  defect  to  heal  by  granulation.  In  more 
severe  cases  the  edematous  swelling  about  the  pustule 
may  be  very  extensive  and  erysipelatous  in  appear- 
ance, associated  with  a  lymphangitis  and  lymphade- 
nitis with  hard  and  tender  lymph  nodes.  The  vesicles 
become  bullae,  contain  a  bloody  fluid,  and  the  ultimate 
suppurative  and  gangrenous  process  may  involve 
areas  as  large  as  the  entire  half  of  the  face.  In  these 
severe  cases  the  constitutional  symptoms  are  marked, 
resembling  those  of  cholera,  with  great  prostration 
and  depression,  a  weak,  rapid  pulse,  often  icterus, 
diarrhea,  delirium,  and  coma. 

In  the  parts  where  there  is  considerable  loose  areolar 
tissue,  as  the  eyelids,  neck,  and  forearm,  great  edema 
may  be  seen.  Here,  instead  of  the  characteristic 
changes  described  above,  the  area  may  have  a  well- 
defined  border  without  vesiculation,  redness,  or  gan- 
grene. There  may  be  little  or  no  pain,  even  in  those 
cases  ending  fatally. 

The   diagnosis   must   be   made   from   the   furuncles 


392  ERYSIPELAS,  ERYSIPELOID,  ANTHRAX 

and  carbuncles.  The  careful  surgeon  will  at  once 
note  that  the  lesion  is  essentially  different  from  these, 
and  will  by  smears  and  culture  determine  the  presence 
of  the  anthrax  bacillus. 

The    statistics   as    to    the    mortality    vary   greatly^ 
being  from  6  to  30  per  cent.     Koch  collected    1413 
published  cases,   with  a  mortality  of  32   per  cent. 
Frazier  summarizes  the  treatment  as  follows: 
To  judge  from  the  experience  of  those  who  are  most 
qualified  to  speak,   the  treatment  of  anthrax  should 
consist  essentially  in   the   administration   of  Sclavo's 
serum,  in  the  excision  of  the  pustule,  and  in  the  appli- 
cation of  certain  bacteriological  agents.     The  serum 
should  be  administered  subcutaneously  and  the  pus- 
tule  should    be   excised    only   when    the   surrounding 
tissues  are  not  very  edematous,  taking  the  precaution 
to  cauterize  the  exposed  surfaces  with  carbolic  acid 
or  the  actual  cautery.     If  the  edema  is  marked,  abso- 
lute rest  of  the  part  should  be  enjoined  and  local  hot 
antiseptic  fomentations,  such  as  bichloride  of  mercury, 
applied.     The  serum  has  no  deleterious  effects,   and 
in  the  hands  of  its  originator  and  others,  especially  in 
Italy  and  England,  the  results  substantiate  the  claims 
which  have  been  made.     It  assists  in  the  destruction 
of  the  bacilli,  before  they  become  so  numerous  that 
their    destruction    by    the    bodily    defences    increases 
the  danger  of  fatal  poisoning  from  the  toxins  set  free 
by  the  disintegration  of  the  bacilli.     When  the  serum 
cannot  be  obtained,  and  when   excision   is   impracti- 
cable, injections  of  carbolic  acid  (5  per  cent.)  should 
be    tried,    introducing    the    needle    at    several    points 
along  the  margin  of  the  pustule  and  infiltrating  the 
base  of  the  pustule  and  surrounding  healthy  tissue. 
These  injections  may    be   repeated   frequently.     The 
constitutional  symptoms  must  be  met  by  appropriate 
and  supportive  measures. 


ANTHRAX  393 

It  has  been  my  fortune  to  meet  with  only  one  case 
of  anthrax.  That  occurred  in  a  man,  aged  thirty- 
five  years,  who  worked  in  the  Chicago  stockyards. 
He  applied  at  the  Cook  County  Hospital  for  treat- 
ment, and  I  regret  to  say  that  the  records  of  the  case 
cannot  be  secured  at  the  present  time.  The  lesion 
was  upon  the  left  forearm  and  presented  the  charac- 
teristic gangrenous  centre.  He  wras  treated  by  local 
antiseptics  and  made  a  prompt  recovery. 


SECTION  V. 

COMPLICATIONS  AND  SEQUELAE  OF  INFECTIONS 
OF  THE  HAND. 


CHAPTER  XXVI. 

FOREARM    INVOLVEMENT   FROM    INFEC- 
TIONS  OF  THE   HAND— PATHOLOGY 
AND   DIAGNOSIS. 

FOREARM  involvement  occurs  in  two  forms — that 
associated  with  lymphangitis  and  that  following  ten- 
don-sheath infection  of  the  flexor  tendons  and  abscesses 
in  the  palm.  These  two  forms  have  been  touched 
upon  in  general  in  discussing  these  infections  in  the 
preceding  chapters.  The  pathology  and  localization  is 
essentially  different,  as  it  arises  from  the  two  sources. 
I  refer,  of  course,  to  suppurative  involvement,  and 
have  no  reference  to  the  edema  which  always  occurs 
with  any  infection.  At  the  risk  of  some  repetition, 
I  shall  review  the  subject  in  general,  so  as  to  give  a 
composite  picture. 

SUBCUTANEOUS  ABSCESSES. 

That  form  due  to  lymphatic  involvement  of  super- 
ficial origin  has  been  referred  to  on  page  326.  We  may 
have  a  secondary  involvement  upon  both  the  flexor 
and  extensor  surfaces.  Upon  the  flexor  surface  we 
find  a  localization  just  above  the  annular  ligament 
in  many  cases  of  deep  infection  of  the  hands,  particu- 


396  FOREARM  INVOLVEMENT 

larly  those  cases  showing  an  ulnar  bursitis.  They 
are  characterized  by  redness  and  slight  induration 
over  an  area  two  or  three  inches  in  length  at  the  lower 
end  of  the  forearm.  The  diagnosis  is  not  difficult, 
the  only  thing  to  be  borne  in  mind  being  that  the 
surgeon  should  understand  its  origin  and  should  not 
desist  from  dealing  with  the  extension  under  the 
tendons  from  a  rupture  of  its  synovial  sheath,  since 
there  is  no  connection  between  these  pockets,  and 
draining  the  superficial  pocket  does  not  drain  the 
deeper  and  more  important  focus. 

Besides  this  well-differentiated  localization,  small 
foci  may  develop  along  the  lines  of  any  lymphatic, 
either  on  the  flexor  or  dorsal  surface.  Care  should 
be  taken  not  to  mistake  these  uncommon  localizations 
for  the  acute  non-suppurative  inflammation  of  the 
lacunae  (see  p.  327).  Again,  localizations  may  take 
place  about  the  glands  of  the  epitrochlear  region,  as 
has  been  described  in  Chapter  XX. 

The  most  important  subcutaneous  accumulation 
associated  with  lymphatic  infection  occurs  upon  the 
dorsum  of  the  forearm.  This  condition,  characterized 
by  a  brawny  induration  of  the  entire  dorsum,  with 
necrosis  and  sloughing  of  the  subcutaneous  tissue,  is 
one  of  the  gravest  complications  met  with  in  hand 
infections.  A  full  discussion  may  be  found  in  Chapters 
XX  and  XXI. 

DEEP  ABSCESSES. 

The  deep  involvement,  no  matter  what  the  origin, 
almost  always  is  found  upon  the  flexor  surface.  This 
most  commonly  arises  through  extension  by  rupture 
of  the  proximal  end  of  the  ulnar  or  radial  bursae  or  by 
extension  from  a  palmar  abscess.  This  is  by  all  odds 
the  most  important  question  we  have  to  deal  with 


ABSCESS  FORMATION  WITHOUT  COMPLICATIONS    397 

when    considering   forearm   involvement.      It   will   be 
discussed  under  three  heads: 

1.  Cases  showing  forearm  abscesses  without  other 
complications. 

2.  Cases  showing  forearm  involvement  with  carpal 
joint  involvement. 

3.  Cases  showing  forearm  involvement  with  second- 
ary hemorrhage. 

FOREARM  INVOLVEMENT:  ABSCESS  FORMATION  WITHOUT  OTHER 
COMPLICATIONS. 

LOCATION  OF  THE  ABSCESSES. — It  has  been  the  habit 
of  surgeons  and  writers  dealing  with  this  subject  to 
speak  of  these  abscesses  in  a  general  way  only,  and  to 
suggest  drainage  through  the  volar  surface  between  the 
tendons  and  muscles.  In  my  earlier  cases  I  was  struck 
with  the  long  convalescence,  the  repeated  incisions, 
and  the  inadequate  drainage  owing  to  the  rapid  closure 
of  the  sinuses  through  the  muscular  bodies.  There- 
fore a  careful  study  of  the  anatomy  of  the  forearm 
was  undertaken  both  by  dissection  of  serial  sections 
and  by  experimental  injections  made  through  the 
various  tendon  sheaths  and  from  other  sites  of  predilec- 
tion of  pus  in  the  hand.  By  this  I  determined  the 
probable  site  of  these  secondary  abscesses  in  the  fore- 
arm. These  experimental  and  anatomical  deductions 
were  verified  by  a  study  of  all  my  cases  showing  this 
complication,  as  well  as  an  extensive  review  of  cases 
reported  in  the  literature.  The  result  was  beyond 
expectation.  The  study  enables  the  surgeon  to  prog- 
nosticate before  operation  the  exact  location  of  pus 
in  the  forearm.  It  suggested  new  sites  for  drainage 
which  cured  cases  in  from  one  to  two  weeks  by  two, 
or  at  most  three,  primary  incisions,  which  by  the  older 
procedures  would  have  required  from  three  to  five 
weeks,  with  the  probability  of  many  complications. 


398  FOREARM  INVOLVEMENT 

The  anatomical  and  experimental  work  I  have 
detailed  in  Chapter  X.  It  remains  for  me,  therefore, 
to  adduce  the  clinical  proof  of  its  correctness  and  sug- 
gest plans  of  treatment.  It  will  be  seen,  by  referring 
to  Chapter  X,  that  the  final  deduction  made  from  the 
researches  was  that  the  important  space  in  which  pus 
would  be  found  in  those  cases  where  the  infection 
originated  in  the  hand  had  the  following  boundaries: 
It  lies  under  the  flexor  profundus  digitorum  tendons 
and  muscle.  About  three  inches  up  on  the  forearm 
the  pus  begins  to  invade  the  intermuscular  septa, 
passing  first  to  the  area  about  the  median  nerve  and 
later  to  the  area  about  the  ulnar  artery  and  nerve. 
Here  it  lies  between  the  flexor  carpi  ulnaris  and  the 
flexor  profundus.  This  is  about  four  inches  up  on 
the  forearm.  From  here  it  may  pass  toward  the  elbow 
along  the  vessels  and  nerves,  particularly  the  median 
nerve,  or  more  commonly  it  may  extend  distally  along 
the  ulnar  artery  under  the  flexor  carpi  ulnaris  and 
appear  subcutaneously  about  three  inches  up  on  the 
ulnar  side.  It  may  extend  downward  along  the  radial 
artery,  but  this  is  certainly  an  uncommon  termination. 
The  largest  part  of  the  space  is  about  two  inches  above 
the  wrist.  Its  most  superficial  parts  are  on  either  side 
just  volar  to  the  ulna  and  radius.  The  floor  of  the 
space  is  made  up  by  the  pronator  quadratus  at  the 
wrist  and  the  interosseous  septum  above.  The  space 
may  hold  a  half  pint  or  more  of  fluid.  No  other  well- 
defined  space  is  present  except  that  comprising  the 
subcutaneous  tissue.  In  corroboration  of  this  state- 
ment, I  shall  make  excerpts  from  some  of  the  cases  that 
have  come  under  my  observation,  and  shall  add  a  few 
from  the  reports  of  Tornier  and  Forssell  to  show  that  my 
deductions  are  unbiased.  That  there  may  be  no  ques- 
tion as  to  the  possibility  of  the  infection  having  arisen 
sequentially  from  a  carpal-joint  involvement,  those 


ABSCESS  FORMATION  WITHOUT  COMPLICATIONS     399 

cases  will  be  excluded  and  only  uncomplicated  forearm 
involvement  discussed.  Altogether  I  have  now  had  37 
cases  showing  this  extension.  The  report  of  the  post- 
mortem in  Case  XXII  may  also  be  noted  in  corrobo- 
ration. 

CASE  XXV. — The  ulnar  bursa  was  opened  and  inci- 
sion extended  to  the  middle  of  the  forearm,  exposing  an 
abscess  lying  mainly  under  the  flexor  profundus  digitorum. 

CASE  XXVI. — The  flexor  side  of  the  forearm  was 
swollen  and  painful  to  the  upper  third,  incision  was 
continued  from  the  ulnar  bursa  on  the  forearm  toward 
the  centre.  In  juxtaposition  to  the  nerves  and  blood- 
vessels a  pocket  of  pus  was  evacuated,  which  extended 
between  the  flexor  sublimis  digitorum  and  the  flexor 
profundus  digitorum,  and  lying  on  the  interosseous  mem- 
brane of  the  upper  half  of  the  forearm. 

CASE  XXVII. — The  hand  and  forearm  were  swollen, 
incision  was  extended  from  the  ulnar  bursa  in  the  fore- 
arm and  the  flexor  muscles  were  separated  by  the  handle 
of  the  scalpel.  The  abscess  extended  along  the  inter- 
osseous  ligament  to  within  a  hand's  breadth  of  the  elbow. 

CASE  XXVIII. — Incision  was  made  opening  the  sheath 
of  the  flexor  longus  pollicis  and  up  to  the  annular  liga- 
ment; a  second  incision  was  made  into  the  same  sheath 
above  the  annular  ligament,  and  this  was  extended  along 
the  lower  half  of  the  forearm  over  the  radial  sources  of  the 
flexor  sublimis  digitorum.  Pus  was  found  along  the  flexor 
longus  pollicis  and  behind  the  flexor  profundus  digitorum 
in  the  lower  third  of  the  forearm. 

CASE  XXIX. — A  large  amount  of  pus  was  shown  in  the 
lower  two-thirds  of  the  forearm  lying  between  the  flexor 
sublimis  digitorum  and  the  flexor  carpi  ulnaris,  below 
the  flexor  profundus,  which  was  entirely  evacuated  by  a 
single  incision  upon  the  ulnar  side  above  the  wrist-joint. 

In  the  following  case  there  was  a  neglected  tendon- 
sheath  infection  on  the  dorsum.  These  cases  are 
extremely  uncommon,  since  they  are  generally  only 
local  abscesses  without  extension. 


400  FOREARM  INVOLVEMENT 

CASE  XXX. — An  infection  extended  upon  the  back 
of  the  forearm;  after  two  superficial  abscesses  had  been 
opened,  it  was  noted  some  days  later  that  there  was  a 
painful  swelling  on  the  dorsal  ulnar  side  of  the  forearm; 
this  was  incised  as  far  as  the  fascia  without  freeing  any 
pus.  A  pocket  was  found,  however,  under  the  dorsal 
annular  ligament  extending  into  the  otherwise  healthy 
muscle  above. 

CASE  XXXI  (Forssell). — A  large  incision  was  made 
on  the  middle  of  the  forearm  down  to  the  palm,  cutting 
the  anterior  annular  ligament  and  part  of  the  palmar 
aponeurosis,  a  large  abscess  was  found  in  the  palm  and 
under  the  annular  ligament  and  in  the  forearm  lying 
between  the  ulnar  muscles  and  the  flexor  profundus 
digitorum.  The  tendon  sheaths  were  entirely  intact. 

CASE  XXXII  (Forssell). — About  a  week  after  the  prim- 
ary injury  there  was  an  increase  of  pain  in  the  arm,  which 
became  red,  sensitive,  and  swollen.  After  four  or  five 
days  pus  was  forced  out  by  pressure  on  the  forearm,  a 
7  cm.  cut  was  made  above  the  wrist  through  the  skin, 
followed  by  a  blunt  dissection  to  the  tendon  sheaths, 
from  which  thin  pus  was  evacuated ;  a  drain  was  inserted 
through  this  opening  under  the  annular  ligament  out 
through  the  hand.  On  the  ulnar  side  of  the  forearm  an 
incision  was  made,  15  cm.  long,  carried  down  between  the 
flexor  profundus  digitorum  and  the  flexor  carpi  ulnaris; 
pus  was  met  with  here  and  the  tendons  of  the  flexor 
profundus  digitorum  were  surrounded  with  pus  in  the 
lower  three-fourths  of  the  forearm. 

CASE  XXXIII  (Tornier). — Two  weeks  after  injury 
it  was  noticed  that  the  entire  arm  was  swollen,  especially 
the  forearm.  On  the  same  day  the  ulnar  bursa  was 
opened,  a  large  amount  of  pus  was  found,  much  burrow- 
ing behind  the  muscles  of  the  forearm,  and  wide  incisions 
were  made  here. 

CASE  XXXIV  (Forssell).— The  lower  third  of  the  fore- 
arm was  swollen  and  tender,  but  the  patient  had  no 
spontaneous  pain.  The  ulnar  bursa  was  opened  through- 
out its  length  and  the  incision  continued  over  the  lower 
third  of  the  forearm.  This  exposed  an  abscess  lying  on 
the  interosseous  membrane  under  the  muscles.  Counter- 
incisions  were  made.  Culture  showed  streptococcus. 


ABSCESS  FORMATION  WITHOUT  COMPLICATIONS  -401 

FKY^tnr  p 

CASE  XXXV  (Tornier). — Incision  was  made  into  the 
radial  bursa  and  on  the  forearm  extending  on  the  radial 
side,  exposing  an  abscess  lying  between  the  pronator 
radii  teres  and  the  flexor  carpi  radialis,  behind  the  deep 
flexors. 

CASE  XXXVI  (Tornier). — Both  bursae  opened,  anterior 
annular  ligament  incised,  large  amount  of  thick  yellowish- 
green  pus  was  found  in  the  lower  part  along  the  inter- 
osseous  membrane. 


FIG.  119 


Photograph  of  cross-section,  7  cm.  above  the  radial  styloid,  showing  area 

filled  with  pus. 

Every  case  that  has  come  under  my  observation 
has  borne  out  these  deductions  and  from  these  reports 
and  my  studies  it  is  certainly  justified  to  outline 
the  position  of  these  secondary  abscesses  as  we  have. 
The  position  of  the  pus  at  a  point  one  and  one-half 
inches  up  on  the  forearm  is  shown  in  cross-section 
(Fig.  119),  and  also  the  position  of  the  pus  when  it 
reaches  the  middle  of  the  arm  is  shown  in  a  second 
cross-section  (Fig.  120). 

SYMPTOMS,  SIGNS,  AND  DIAGNOSIS. — The  diagnosis 

of  a  forearm  involvement  is  based  on  the  knowledge 

of  an  associated  tendon-sheath  infection  of  the  ulnar 

or  radial  bursse  or  a  middle  palmar  infection  and  the 

26 


10  N  NfXhfel- 

403.  rjFQX&A'&M  INVOLVEMENT 

tUYi^oTVoO    -  - -l  .; 

\^^i.BJghs  inci^erti  TO  the  development  of  any  deep  abscess. 
Especially  in  an  ulnar  bursitis  which  has  existed  two 
or  more  days  before  drainage  do  we  look  for  a  beginning 
forearm  involvement.  In  any  case,  we  have  the  devel- 
opment of  increased  swelling  of  the  forearm.  The 
swollen  part  has  not  the  soft  feeling  incident  to  edema, 
but  a  full,  tense  feeling  as  if  the  forearm  were  an  over- 
distended  bag.  There  may  be  but  little  increase  in 
redness.  The  induration  seen  in  subcutaneous  abscesses 
will  be  absent.  However,  tenderness  to  deep  pressure 

FIG.  120 


Photograph  of  forearm  just  below  the  middle,  showing  position  of  pus  in 
its  relation  to  the  ulnar  artery  and  the  median  nerve. 

is  increased.  The  wrist  becomes  more  or  less  fixed 
and  the  careful  observer  has  no  difficulty  in  suggesting 
the  diagnosis  on  the  history  of  these  findings.  Of 
course,  later,  when  the  pus  had  infiltrated  every 
part,  even  the  novice  can  make  the  diagnosis.  Early 
diagnosis  is  greatly  to  be  desired,  however.  It  should 
be  urged  that  in  case  of  doubt  incision  may  be  made 
after  the  manner  already  suggested,  by  lateral  incisions, 
without  in  any  way  jeopardizing  the  patient's  forearm. 
Whenever  I  open  an  ulnar  or  radial  bursa,  and  there  is 


INVOLVEMENT   WITH  WRIST-JOINT  INVASION    403 

any  question  in  my  mind  as  to  forearm  involvement, 
the  forearm  incisions  are  made.  Indeed,  these  same 
incisions  may  be  used  to  drain  the  upper  end  of  the 
sheaths  in  the  forearm.  So  that  the  incisions  thus 
serve  two  purposes — they  drain  the  bursae,  and  if 
pus  is  already  in  the  forearm  or  develops  subsequently, 
they  afford  it  an  immediate  outlet. 


DEEP  FOREARM  INVOLVEMENT  ASSOCIATED  WITH  WRIST-JOINT 
INVASION. 

If  operated  upon  early  the  involvement  of  the  wrist- 
joint  will  be  uncommon.  In  certain  cases,  however, 
it  will  be  met  with  either  early  in  the  course  or  later 
as  a  complication.  The  wrist-joint  involvement  is  a 
most  serious  complication,  and  it  should  be  watched 
for,  particularly  in  aged  patients  with  involvement  of 
the  radial  bursa  (tendon  sheath  of  the  flexor  longus 
pollicis).  By  reference  to  the  cases  it  will  be  seen 
that  of  the  8  cases  here  reported,  7  were  fifty-four 
years  of  age  or  older.  It  is  to  be  noted  particularly, 
however,  that  every  case  was  one  of  involvement  of 
the  radial  bursa,  either  alone  or  in  conjunction  with 
other  foci.  In  5,  the  primary  process  was  in  the  thumb. 
One  cannot  help  but  feel  that  this  is  more  than  a 
coincidence;  as  yet,  however,  no  definite  anatomical 
reason  can  be  adduced  to  explain  it.  In  none  of 
my  injections  of  this  synovial  sheath  has  the  mass 
ruptured  or  extended  into  the  wrist-joint. 

EXAMINATION  OF  THE  RADIAL  BURSA  IN  CADAVERS. 
—To  determine  whether  or  not  there  is  at  times  a 
normal  opening  connecting  the  radial  bursa  and  the 
wrist-joint,  with  the  assistance  of  Prof.  P.  T.  Burns 
and  Dr.  A.  T.  Horn,  of  the  Anatomical  Department 
of  the  Northwestern  University  Medical  College,  I 
have  examined  30  cadavers,  and  in  no  one  of  them 


404  FOREARM  INVOLVEMENT 

have  we  found  any  normal*  opening,  although  Prof. 
Burns  states  that  he  has  at  times  noted  such  a  com- 
munication. This  is  borne  out  by  other  observers, 
but  it  must  be  extremely  rare.  According  to  Schwartz, 
the  parietal  layer  of  the  ulnar  bursa  is  attached  to  the 
ligaments  and  periosteum  of  the  carpal  bones,  par- 
ticularly the  unciform  and  os  magnum.  Forssell 
states  that  in  cases  of  carpal  involvement  he  has  noted 
that  the  os  magnum  suffers  the  greatest  destruction 
(Fig.  121). 

FIG.  121 

pscs 


IPMP5 


Drawing  showing  intimate  relation  of  the  ulnar  bursa  to  the  os  magnum 
and  its  early  involvement.  Notice  the  association  of  the  radial  bursa  and 
the  trapezium:  DSCS,  dorsal  subcutaneous  space;  IPMPS,  infected  process 
leading  from  middle  palmar  space;  IUB,  infected  ulnar  bursa;  O,  ostium; 
OM,  os  magnum;  RB,  radial  bursa;  S,  sinus;  UV  and  A,  ulnar  vein  and 
artery. 

PATHOLOGY  FOUND  IN  SERIOUS  WRIST-JOINT  IN- 
VOLVEMENT.— Since  my  own  experience  with  this  condi- 
tion is  rare,  I  have  been  compelled  to  turn  to  the  litera- 
ture for  reports  of  postmortems.  Of  my  personal  cases, 
5  in  number,  all  recovered.  One  case  (Case  XLIX) 


INVOLVEMENT  WITH  WRIST-JOINT  INVASION    405 

is  found  in  the  chapter  dealing  with  Osteomyelitis. 
Owing  to  the  seriousness  of  this  complication,  one  may 
be  pardoned  for  making  rather  complete  reports. 

In  the  first  case  the  position  of  the  sinus  openings 
on  either  side  above  the  annular  ligament  at  the  site 
of  the  two  vessels  emphasizes  the  tendency  of  these 
abscesses  to  follow  the  vessels  (see  Experiment  47, 
where  the  only  place  the  mass  became  subcutaneous 
was  on  the  ulnar  side  just  above  the  annular  ligament). 
The  absence  of  tenderness  and  pain  about  the  necrotic 
joint  is  also  worthy  of  note.  The  involvement  of  the 
radio-ulnar  joint,  as  here  noted,  is  a  frequent 
complication. 

CASE  XXXVII  (Bauchet). — Deep  phlegmon  of  the 
right  thumb;  deep  phlegmon  of  the  hand;  phlegmon  of 
the  forearm;  fistulous  processes;  abundant  suppuration. 
Great  scar  over  the  sacrum;  septic  infection.  Death. 
Postmortem. 

This  man,  between  fifty-five  and  sixty  years  old,  gives 
a  history  of  an  inflammation  of  the  thumb  two  months 
before  entrance.  On  the  forearm  there  are  two  openings ; 
one  is  at  the  inside  and  the  other  at  the  outside  of  the 
anterior  surface;  both  are  about  4  cm.  from  the  radio- 
carpal  joint.  These  two  openings  are  longitudinal,  about 
2  cm.  long,  with  edges  grayish  and  fungous.  At  the  level 
of  the  first  phalanx  of  the  thumb  one  sees  the  scar  of  a 
former  purulent  focus.  No  redness;  dorsal  aspect  of  the 
hand  shows  no  tumefaction;  no  sinuses.  Tenderness  to 
pressure  is  not  very  acute;  the  wrist  is  neither  swollen 
nor  painful.  By  pressing  on  tfie  palm  of  the  hand  or  on 
the  lower  part  of  the  forearm,  one  causes  a  notable  quantity 
of  whitish,  poorly  mixed,  fluid  pus,  without  a  bad  odor, 
to  flow  out  through  the  openings  already  mentioned. 
The  probe  introduced  through  these  openings  slides  a 
considerable  distance  along  the  lower  layers  of  the  fore- 
arm, but  meets  no  denuded  portions  of  the  bone. 

Aside  from  the  two  openings  already  mentioned,  one 
notes  still  farther  inward,  at  the  level  of  the  upper  third 
of  the  anterior  surface,  a  small  opening  from  which  pus 


406  FOREARM  INVOLVEMENT 

escapes,  but  in  smaller  quantity  than  from  the  other  two 
openings. 

By  pressing  the  ulna,  the  radius,  and  at  the  same  time 
trying  to  make  the  patient  move  the  wrist,  one  notes  a 
grating  between  the  ulna  and  the  radius  and  between  these 
bones  and  those  of  the  wrist,  which  resembles  nothing 
more  than  two  nuts  being  rubbed  together. 

Diagnosis. — Deep  whitlow  of  the  thumb;  extension 
of  inflammation  into  the  great  common  synovial  sheath 
of  the  tendon  of  the  little  finger;  rupture  of  the  focus 
between  the  muscular  layers  of  the  forearm,  but  more 
especially  of  the  deeper  part;  extension  of  the  suppura- 
tion to  the  carpal  joints;  necrosis  of  the  bones. 

Postmortem. — The  tendons  are  fixed  in  an  invariable 
position,  and  to  free  them  it  is  necessary  to  cut  out  the 
resisting  fibrous  adhesions.  These  changes  are  evident 
in  the  palm  of  the  hand,  under  the  annular  ligament, 
and  the  lower  part  of  the  forearm,  all  along  the  synovial 
sac.  These  changes  extend  to  the  ends  of  the  tendons 
of  the  thumb  and  little  finger.  They  stop  slightly  above 
the  metacarpophalangeal  joints  of  the  index,  middle,  and 
ring  fingers.  Along  these  fingers  the  synovial  sheaths 
and  the  tendons  are  absolutely  intact.  The  large  focus, 
black  and  purulent,  has  an  exit  in  the  two  openings  before 
mentioned.  At  the  upper  and  outer  part  it  is  closed,  and 
the  muscles  of  the  forearm  on  this  side  are  healthy.  On 
the  ulnar  side,  on  the  contrary,  the  fibrosynovial  sac  is 
frayed,  and  the  pus  has  spread  to  the  level  of  the  upper 
part  of  the  forearm,  between  the  deep  and  superficial 
muscular  layers.  This  purulent  focus,  formed  by  a 
rupture  of  the  synovial  sheath,  has  its  exit  in  the  smaller 
opening,  which  has  already  come  under  discussion. 

The  joints,  radiocarpal,  radio-ulnar,  and  carpal,  are 
open  anteriorly  and  communicate  extensively  with  the 
palmar  purulent  focus,  through  several  openings.  The 
bones  are  neither  red  nor  spotted  nor  crumbling.  They 
are  rather  of  an  ivory-gray  color  and,  in  spots,  blackish; 
there  is  no  false  membrane  or  generative  abscess  in  the 
joint;  but  the  cartilage  has  been  destroyed,  almost  entirely 
resorbed,  and  has  disappeared;  the  bones  bared  of  this 
cartilage  resemble  bones  which  have  been  soaked  in  water 
for  some  time. 


INVOLVEMENT  WITH  WRIST-JOINT  INVASION     407 

The  following  case,  reported  in  the  inaugural  dis- 
sertation of  Max  Tornier,  from  the  Griefswald  Clinic 
(Prof.  Helferich),  emphasizes  again  the  frequency  of 
sinus  openings  in  carpal  involvement  at  the  sites  we 
have  mentioned. 

CASE  XXXVIII. — Phlegmon  of  the  forearm,  involve- 
ment of  carpal,  and  radiocarpal  joints. 

Man,  aged  fifty-eight  years.  On  the  ulnar  side  of  the 
wrist  there  is  a  sinus  opening  4  cm.  long,  through  which 
a  probe  reaches  down  into  the  wrist-joint.  Under  nar- 
cosis and  anemia,  Langenbeck's  incision,  the  tendon  of 
the  long  radial  muscle,  infiltrated  with  pus,  was  resected 
for  about  8  cm.  Resection  of  the  proximal  line  of  the 
carpal  bones,  between  which  small  masses  of  pus  were 
found.  Drainage  established.  Very  dilatory  course ;  the 
distal  row  of  carpal  bones  sloughed  through  necrosis. 
An  erysipelas  with  numerous  abscesses  on  the  forearm 
made  further  incisions  necessary.  When  dismissed  the 
incisions  were  healed;  the  wrist  hung  loose. 

The  following  case  from  the  same  report  shows  the 
beneficial  results  of  early  and  radical  operation  in  the 
case  of  wrist-joint  involvement,  and  shows  the  inade- 
quacy of  superficial  incisions  on  the  forearm. 

CASE  XXXIX. — Severe  phlegmon  of  the  hand  and  fore- 
arm; caries,  of  carpal  and  radiocarpal  joints. 

Patient,  aged  sixty-three  years.  Two  weeks  after  infec- 
tion, incision  over  abscess  on  flexor  and  extensor  sides  of 
forearm.  Two  weeks  later,  second  incision  through  the 
intermuscular  spaces  to  the  ligamentum  interosseum. 
lodoform  drainage.  No  fever  in  evenings. 

The  probe  in  the  wound  of  the  dorsal  incision  strikes 
carious  bones  of  the  wrist;  it  is  pushed  on  in  the  direction 
of  the  dorsoradial  incision  to  the  wrist-joint.  The  latter 
is  opened,  and  shows  destruction  of  the  cartilage  and  the 
bone.  The  joint  is  filled  with  pus.  Resection  of  the 
navicular,  semilunar,  trapezium,  and  trapezoid.  Good 
healing  under  Langenbeck's  extension  bandage.  Good 
granulation.  Daily  massage.  Patient  dismissed  for  a 
few  days  and  did  not  return. 


408  FOREARM  INVOLVEMENT 

Beside  demonstrating  the  pathology  of  severe  cases 
of  carpal  involvement  and  the  extension  of  infection 
to  this  and  the  forearm,  from  the  tendon  sheaths, 
Case  XL  emphasizes  the  error  that  often  occurs  in 
mistaking  for  pus  the  enormous  edema  which  is  found 
upon  the  dorsum  in  these  cases  of  palmar  infections. 

CASE  XL  (Forssell). — Suppuration  of  the  radial  and 
ulnar  bursae  with  involvement  of  the  radio-ulnar  radio- 
carpal,  and  carpal  joints  and  forearm. 

J.  L.,  aged  fifty-four  years.  Woman.  Pain  in  the  left 
hand  from  no  known  reason;  three  days  later  visited 
hospital.  Seven  days  later,  left  hand  (except  for  thumb 
and  second  and  third  phalanges  of  the  other  fingers) 
and  to  a  certain  extent  the  whole  arm  are  swollen;  pain 
over  the  whole  back  of  hand,  more  in  the  palm,  especially 
in  the  fourth  interosseous  space.  Finger  half  bent;  exten- 
sion very  painful.  Temperature,  100.5°.  Incision  of  the 
dorsum  on  the  same  day;  little  pus.  Incision  along  the 
tendon  sheaths  of  the  first  and  fifth  fingers;  communica- 
tion established  between  this  and  incision  above  the  liga- 
ment. Also  incision  over  the  flexor  carpi  ulnaris,  with 
communication  with  the  last-mentioned  incision.  Pus  in 
large  quantities  from  all  the  incisions. 

Four  weeks  after  onset  of  infection  the  tendons  removed 
so  far  as  they  appeared  infected.  All  carpal  bones  removed 
with  a  curette  except  the  trapezium  and  the  upper  part 
of  the  third  metacarpal  bone. 

Discharged  after  three  months  with  ankylosis  of  the 
joint  of  the  hand. 

CASE  XLI  (Forssell). — Tenosynovitis  of  radial  and 
ulnar  bursae,  with  involvement  of  the  carpus. 

G.  K.,  aged  sixty  years,  January  7,  1898.  After  a  small 
wound  at  the  end  of  the  thumb,  symptoms  of  tenosynovitis 
in  the  thumb  and  little  finger.  Same  day,  incision  in  the 
tendon  sheath  of  the  thumb. 

January  8.  The  ulnar  bursa  was  completely  cleft; 
incision  into  the  upper  part  of  the  radial  bursa. 

Aside  from  an  insignificant  necrosis  of  the  thumb 
and  little  finger  tendons,  all  went  well  until  January  16, 
when  symptoms  of  an  infection  of  the  wrist  arose.  These 


INVOLVEMENT  WITH  WRIST- JOINT  INVASION    409 

increased,  and  (January  18)  necessitated  an  incision  into 
the  wrist-joint,  a  considerable  serofibrinous  secretion 
being  found.  Joint  washed  out  with  I  per  cent,  sublimate 
solution.  Gradually  distinct  formation  of  pus  took  place, 
which  led  to  a  partial  resection  of  the  wrist  (February  5). 

In  the  following  case  the  decreased  sensitiveness  in 
the  area  of  the  distribution  of  the  median  nerve  serves 
to  emphasize  the  tendency  of  infection  to  spread  along 
that  nerve,  as  demonstrated  in  Experiment  47  and 
shown  in  Fig.  120. 

CASE  XLII  (Forssell). — Tenosynovitis  of  the  thumb, 
little  finger,  and  ulnar  bursae.  Phlegmon  of  the  forearm 
and  articulation  between  hand  and  forearm. 

S.  T.,  aged  thirty-three  years,  female.  April  4,  1898. 
Distinct  symptoms  of  suppuration  of  the  carpal  "tendon 
sheaths  (tendon  sheath  of  the  little  finger  intact)  and 
on  the  forearm.  Only  slight  pain  on  passive  movements 
of  the  finger;  "the  finger  twinges;"  the  same  is  true  of 
palpation  of  the  palm  and  the  flexor  side  of  the  forearm. 
Complete  opening  of  the  ulnar  bursa;  by  mistake  the 
sheath  of  the  little  finger  was  opened;  no  pus;  incision 
into  the  thumb;  pus  within  and  without  the  sheath. 

April  II.  Incision  into  the  lower  part  of  the  forearm 
down  to  the  ulna  (burrowing  of  pus).  For  three  days 
there  have  been  symptoms  of  infection  of  the  wrist- 
joint;  pus  pours  from  a  small  hole  in  the  capsule  between 
the  pisiform  and  cuneiform.  Around  the  tendon  of  the 
flexor  longus  pollicis  there  is  much  pus,  wherefore  an 
incision  of  the  same  is  made;  it  was  especially  necrotic 
in  the  region  of  the  carpal  ligament;  here  there  is  also 
necrosis  of  other  tendons. 

April  12.  Much  pus  in  the  wrist  and  upper  arm. 
Several  carpal  bones  removed  under  anesthetic. 

April  1 6.  Temperature,  102°  to  105°.  Amputation 
of  the  arm.  Examination  of  the  amputated  arm;  elbow- 
joint  intact;  all  pus  cavities  opened  except  the  suppurated 
tendon  sheaths  of  the  fourth  and  third  fingers.  Necrosis 
of  all  tendons  at  the  anterior  annular  ligament;  the  con- 
dition of  the  median  nerve  was  by  mistake  not  investigated. 

April  17.     Exitus  12  M. 


410  FOREARM  INVOLVEMENT 

Epicrisis. — Worthy  of  notice  was  the  decreased  sensi- 
tiveness and  pain  in  the  median  region,  due  probably 
to  the  compression  of  the  nerve.  The  inflammation  of 
the  wrist  was  possibly  due  to  the  infection  of  the  joint 
between  the  pisiform  and  the  cuneiform;  in  the  capsule 
of  this  joint  a  certain  defect  was  noted,  whether  primary 
or  secondary,  still  pointing  to  a  certain  weakness  in  the 
boundary  of  the  canal  toward  the  carpal  canal. 

In  the  subjoined  case  the  wrist  did  not  become  in- 
volved until  fifteen  days  after  the  beginning  of  the 
infection.  In  this  case,  as  in  many  of  the  others 
reported  here,  there  may  be  some  question  as  to 
whether  or  not  the  incisions  were  made  early  enough 
and  at  the  proper  sites.  Throughout  the  literature  it 
is  evident  that  surgeons  have  paid  too  little  attention 
to  the  fascial  pockets  in  which  pus  lies,  confining  their 
attention  almost  entirely  to  the  tendon  sheaths. 

CASE  XLIII. — Compound  dislocation  of  thumb.  In- 
fection of  radial  and  ulnar  bursse,  resection  of  necrotic 
carpal  bones. 

C.  E.,  aged  fifty-eight  years.  A  large  quantity  of 
grayish-yellow,  thinly  fluid  pus  was  freed  by  opening  the 
radial  bursa.  An  incision  which  had  been  made  on  the 
volar  side  of  the  thumb  lengthened,  and  the  tendon  cut 
out. 

May  20.  Complete  splitting  of  the  ulnar  bursa  and 
the  tendon  sheath  of  the  little  finger;  in  the  bursa  and 
the  tendon  sheath  a  yellowish  fluid  pus.  No  burrowing 
toward  the  forearm  could  be  discovered.  The  swelling 
on  the  hand  went  down.  On  May  24  it  is  especially 
noted  that  there  is  no  swelling  around  the  wrist-joint. 
The  superficial  tendons  of  the  little  finger  had  become 
necrotic  just  below  the  carpal  ligament,  and  those  of  the 
fourth  finger  as  well  showed  beginning  of  necrosis  here. 

May  29.  Temperature,  37.3°  to  37.4°.  Slight  pain 
in  the  hand  near  the  wound  in  the  carpal  region.  Several 
tendons  showed  signs  of  necrosis.  On  the  anterior  side 
of  the  wrist,  exposed  bone  (radius,  carpal  bone?)  can  be 
felt. 


FOREARM  INVOLVEMENT  WITH  HEMORRHAGE    411 

June  7.  Temperature,  37.4°  to  38.2°.  Partial  resec- 
tion of  the  wrist-joint.  Removal  of  the  carpal  bones 
except  the  trapezium  and  pisiform;  unciform  necrotic. 

By  these  cases  I  have  attempted  to  portray  the 
pathology,  symptomatology,  and  course  of  these  fore- 
arm cases,  complicated  by  wrist-joint  involvement. 
The  diagnosis  of  its  occurrence  depends  upon  the 
crepitation  noted  in  the  joint,  associated  with  an 
increase  of  tenderness  and  swelling  about  the  joint. 
It  will  be  remembered  that  the  original  infection  is 
upon  the  flexor  surface.  The  swelling  and  tenderness 
are  here.  When  the  joint  becomes  involved  the  dorsum 
also  partakes  of  this.  Under  normal  conditions  a 
depression  is  noted  on  the  back  of  the  wrist-joint  to 
the  radial  side  of  the  extensor  communis  tendons  at 
the  lower  end  of  the  radius.  This  marks  the  site 
of  the  radiocarpal  articulation.  When  this  fills  with 
fluid  the  depression  is  replaced  by  a  fluctuating  swell- 
ing, and  in  case  of  doubt  a  needle  can  be  inserted 
here  and  the  contents  of  the  joint  aspirated  for  diag- 
nostic purposes.  This  site  is  particularly  indicated  in 
doubtful  cases,  since,  the  original  infection  being  upon 
the  palmar  side,  there  is  no  great  danger  of  infecting 
the  joint  if  it  is  not  already  involved. 

FOREARM  INVOLVEMENT  WITH  SECONDARY  HEMORRHAGE. 

One  of  the  most  serious  complications  met  with  in 
the  later  stages  of  forearm  involvement  is  that  of 
hemorrhage.  The  onset  of  a  sudden,  profuse  hemor- 
rhage in  a  patient  who  is  unable  to  care  for  himself 
in  the  temporary  absence  of  attendants  may  lead  to  an 
immediate  lethal  issue.  The  condition  is  especially 
dreaded,  since  the  surgeon  looks  upon  the  condition 
as  most  difficult  to  handle,  since  he  fears  to  undertake 
the  dissection  which  he  believes  to  be  necessary  to 


412  FOREARM  INVOLVEMENT 

find  the  point  of  hemorrhage  and  ligate.  He  therefore 
temporizes  with  a  bandaging  of  the  arm  and  tampor 
nade,  only  to  be  subjected  to  greater  anxiety  on  account 
of  a  subsequent  hemorrhage.  It  would  seem  that  this 
complication  may  be  successfully  dealt  with  if  the 
surgeon  will  only  have  in  mind  the  following  facts: 

1.  The  vessel  nearly  always  at  fault  is  the  ulnar. 

2.  The  surgeon  should  not  temporize,  but  cut  down 
upon  and  ligate  at  once  the  bleeding  vessel. 

The  reason  for  the  involvement  of  the  ulnar  vessel 
is  seen  by  examining  the  cross-sections  (Figs.  55  to 
59,  and  120),  in  which  it  is  shown  that  the  pus  early 
involves  this  vessel.  The  line  of  extension  is  along 
this  vessel,  both  up  toward  the  elbow  and  downward 
to  the  ulnar  side  of  the  forearm.  The  radial  is  well 
separated  from  the  space  in  a  majority  of  cases. 

My  statements  do  not  depend  alone  upon  my 
anatomical  and  experimental  studies.  Clinical  proof 
in  support  of  it  can  be  adduced  from  my  experience, 
and  also  from  numerous  cases  reported  in  the  literature. 
I  will  let  two  cases  suffice  for  that:  one  that  came 
under  my  observation,  and  one  from  the  service  of 
Prof.  Velpeau  in  which  a  postmortem  was  performed. 
This  latter  is  added  for  the  further  reason  that  the 
postmortem  serves  to  give  further  corroboration  to  my 
statements  as  to  the  position  of  pus  in  these  cases, 
a  fact  which  cannot  be  definitely  proved  except  by 
postmortem.  My  own  case  I  shall  report  briefly. 

CASE  XLIV.— Mr.  H.  Referred  to  Dr.  Richter  at  the 
Post-Graduate  Hospital,  with  whom  I  saw  the  patient 
in  consultation. 

Ten  days  previous  to  the  onset  of  the  first  hemorrhage 
the  patient  had  suffered  from  a  tendon-sheath  infection 
of  the  ulnar  and  radial  bursae,  with  extension  into  the 
forearm.  The  infection  had  not  been  opened  promptly, 
and  even  after  the  primary  incisions  the  drainage  from 
the  forearm  had  not  been  satisfactory.  Dr.  Richter  had 


FOREARM  INVOLVEMENT  WITH  HEMORRHAGE    413 

made  free  drainage,  but  by  that  time  the  vitality  of  the 
vessel  had  been  impaired.  A  sudden  profuse  hemorrhage 
occurred,  which  jeopardized  the  patient's  life  before  it  was 
discovered  by  the  nurse.  A  constrictor  about  the  arm 
and  tamponade  completely  controlled  the  hemorrhage, 
and  it  was  felt  that  it  would  not  recur.  However,  two 
days  later  a  second  profuse  hemorrhage  occurred,  and  the 
ulnar  vessel  was  cut  down  upon  as  soon  as  the  patient 
had  recovered  from  the  severe  shock.  The  source  was 
found  to  be  the  ulnar,  as  had  been  prognosticated.  It 
was  ligated  with  catgut,  and  the  patient  made  an  un- 
eventful recovery.  Function  in  the  hand,  however,  was 
impaired. 

The  history  of  the  following  case,  made  the  more 
interesting  by  the  personal  attention  of  the  eminent 
Prof.  Velpeau,  serves  further  to  emphasize  the  possi- 
bility of  hemorrhage  from  ulceration  of  the  ulnar 
vessel.  The  presence  of  the  fistulous  tracts  near  the 
annular  ligament  suggested  the  necrosis  of  the  carpal 
bones  which  was  present,  and  the  deep  position  of  the 
pus  in  the  forearm  is  worthy  of  note.  The  whole 
clinical  picture  was  one  of  extensive  involvement  of 
the  wrist-joint,  deep  phlegmon  of  the  arm,  and  the 
infection  of  synovial  sheaths  which  at  a  later  day 
would  in  all  probability  have  been  relieved  by  opera- 
tive procedure. 

CASE  XLV  (Bauchet).— Whitlow  of  the  left  thumb 
caused  by  a  prick  of  a  needle;  multiple  abscesses  pro- 
duced by  the  spread  along  the  synovial  sheath  to  the 
wrist  and  forearm.  Hospital  gangrene  complicating  the 
abscesses  of  the  wrist  and  following  the  tissues  along  the 
ulnar  artery,  severe  hemorrhage,  tamponade,  tourniquet; 
gangrene  of  hand  and  forearm;  amputation;  danger  of 
hospital  gangrene  in  stump.  Recovery. 

Patient,  aged  fifty  years,  in  the  service  of  M.  Velpeau, 
Charity  Hospital;  sick  for  two  and  one-half  months; 
entered  April  25,  1851;  was  dismissed  August  13. 

About  two  and  one-half  months  ago  the  patient  pricked 


414  FOREARM  INVOLVEMENT 

the  thumb  of  his  left  hand  with  a  needle.  There  resulted 
a  phlegmon  of  this  finger  which  extended  rapidly  over 
the  whole  hand;  abscesses  formed  on  the  palmar  aspect 
of  the  finger  and  hand,  some  of  which  opened  simulta- 
neously and  some  of  which  were  opened  by  a  bistoury; 
the  swelling  persisted,  and  even  spread  through  the  entire 
thickness  of  the  wrist  and  forearm,  along  the  synovial 
sheath. 

On  the  palmar  face  of  the  wrist  one  notes  several  sinus 
openings  from  which  passes  a  purulent  fluid,  viscid, 
clear,  and  thready;  by  pressing  the  palmar  surface  from 
below  upward,  one  causes  this  liquid  to  flow  back.  These 
openings  seem  to  communicate  freely  with  the  synovial 
sheaths  of  the  flexor  tendons  of  the  fingers  at  the  level 
of  the  wrist. 

The  inflammation  spreading  from  the  hand  to  the 
forearm  along  these  channels  is  very  intense,  and  pre- 
sents the  characteristics  of  a  diffuse  phlegmon.  During 
the  next  seven  weeks  the  patient  was  treated  in  an 
expectant  manner. 

June  20.  Appearance  of  hospital  gangrene.  The  open- 
ings on  the  palmar  aspect  of  the  wrist  are  larger,  puffed 
up,  mushroom-like,  and  forming  a  large  projection  show- 
ing a  spongy,  fungous,  grayish  aspect. 

June  28.  Growth  of  the  wound,  which  now  covers 
the  whole  palmar  face  of  the  wrist.  Sinking  of  the  mush- 
room-like elevation  of  flesh.  All  the  tissues  between  the 
skin  and  the  bones  of  the  wrist  are  in  a  state  of  putrilage, 
and  the  flexor  tendons  are  floating  in  this  decomposed 
matter.  These  tendons  are  stripped  of  their  sheath, 
exfoliated,  and  have  lost  their  silvery  appearance. 

June  29.  During  the  preceding  night  considerable 
hemorrhage  from  the  ulnar  artery. 

After  several  days  hospital  gangrene  developed  in  the 
hand,  and  Prof.  Velpeau  amputated  at  the  upper  third 
of  the  forearm.  The  patient  then  made  a  rapid  recovery. 

Pathological  anatomy  of  the  amputated  member.  A 
careful  dissection  permits  one  to  ascertain  that  the  ulcer- 
ation  involves  only  the  ulnar  artery;  the  central  end  of 
this  artery  is  stopped  by  a  blood-clot.  The  radial  artery 
in  the  gangrenous  portion  is  filled  with  fibrinous  clots. 

Upon   examining   the  other   tissues,   one   notes   at   the 


RESUME  415 

level  of  the  focus  of  the  palmar  abscess  purulent  trails 
which  ascend  the  length  of  the  forearm  in  the  tendinous 
grooves,  and  the  length  of  the  aponeurotic  sheaths  of 
the  muscles  of  the  anterior  aspect  of  the  forearm,  to  the 
level  at  which  the  forearm  was  amputated.  One  notes, 
moreover,  an  infiltration  of  purulent  fluid  between  these 
grooves  and  these  aponeurotic  sheaths.  The  connective 
tissue  of  the  forearm  is  infiltrated  like  lard.  The  tissues 
of  the  hand  are  completely  sphacelated,  dead,  and  black. 

From  all  the  evidence,  therefore,  one  is  justified  in 
assuming  that  in  the  ordinary  case  the  hemorrhage 
arises  from  the  ulnar  artery,  and  proceeding  after 
the  manner  suggested  below  when  dealing  with  this 
complication. 

RESUME. 

Subcutaneous  abscesses  ordinarily  develop  on  the 
back  of  the  forearm  but  may  involve  the  subcutaneous 
tissue  proximal  to  and  above  the  anterior  annular 
ligament.  This  especially  accompanies  ulnar  bursitis. 

Deep  abscesses  of  the  forearm  are  practically  always 
found  upon  the  flexor  surface  and  almost  always  come 
from  a  rupture  of  the  proximal  end  of  the  ulnar  or 
radial  bursae.  These  abscesses  practically  always  lie 
underneath  the  flexor  profundus  tendons  and  muscles 
and  on  the  pronator  quadratus  and  interosseous 
septum.  The  diagnosis  is  made  upon  an  associated 
tendon-sheath  infection  with  an  increase  of  swelling 
and  pain  in  the  forearm. 

The  wrist-joint  may  be  involved  particularly  in 
aged  patients  with  radial  bursitis.  It  is  evidenced 
by  bony  crepitus  due  to  destruction  of  the  bones, 
particularly  the  os  magnum.  Secondary  hemorrhage 
occurring  in  the  forearm  follows  long-continued  sup- 
puration about  the  vessels,  especially  the  ulnar  artery. 
The  surgeon  should  not  temporize  but  cut  down  and 
ligate  the  bleeding  vessels. 


CHAPTER  XXVII.- 

TREATMENT  OF   INVOLVEMENT  OF   THE 

FOREARM   SECONDARY  TO   HAND 

INFECTIONS. 

TREATMENT  OF   UNCOMPLICATED   CASES. 

THE  treatment  of  the  subcutaneous  abscesses  sec- 
ondary to  lymphangitis  has  been  discussed  in  Chapter 
XXIII. 

In  dealing  with  the  deep  forearm  involvement,  two 
methods  may  be  used:  (i)  The  older  procedures  by 
which  the  incision  which  opened  the  ulnar  bursa  may 
be  continued  upward  into  the  forearm,  cutting  the 
anterior  annular  ligament  (see  p.  269  for  full  descrip- 
tion of  this  method).  This  procedure,  however,  I 
have  abandoned  except  in  rare  cases.  (2)  Follow- 
ing the  anatomical  studies  described  in  previous  chap- 
ters, I  have  used  lateral  incisions  upon  either  side 
above  the  wrist  (Fig.  122).  In  many  cases  only  one 
has  been  used,  that  upon  the  ulnar  side.  By  referring 
to  the  cross-sections  and  Figs.  123  to  126,  the  site 
of  these  incisions  may  be  seen.  I  begin  my  incision 
about  an  inch  above  the  styloid  process  of  the  ulna 
and  carry  it  upward  for  about  three  inches,  cutting 
down  to  the  ulna  on  a  level  with  its  volar  surface. 
The  attachment  of  the  deep  fascia  to  the  bone  is  sep- 
arated and  then  the  finger  is  inserted  between  the  ten- 
dons and  the  pronator  quadratus.  A  free  opening  is 
secured.  If  it  is  deemed  wise  to  make  a  second  incision 
upon  the  radial  side,  an  artery  forceps  is  passed  across 
from  the  ulnar  side  (Fig.  123).  The  forceps  should 


TREATMENT  OF  UNCOMPLICATED  CASES        417 

hug  the  radius  closely,  and  when  the  point  impinges 
upon  the  skin  of  the  radial  side  an  incision  is  made 
through  the  skin  for  a  distance  of  a  couple  of  inches. 


FIG.  122 


Lines  represent  the  various  incisions  made  for  drainage  of  the  infected 
tendon  sheaths  and  their  possible  extensions  into  the  forearm.  (See  text 
for  complete  description.) 


FIG.  123 


m.n.     r.a. 


u.a. 
u.n. 


Cross-section  7  cm.  above  radial  styloid.  Artery  forceps  inserted  trans- 
versely in  juxtaposition  to  ulna  and  radius  through  the  anterior  interosseous 
space,  showing  that  incision  can  be  made  here  and  not  injure  important 
vessels  and  nerves.  Notice  tissue  between  radial  artery  and  the  forceps. 
r.  a.,  radial  artery;  u.  a.,  ulnar  artery;  u.  n.,  ulnar  nerve;  m.  n.,  median  nerve. 


The    opening   is   enlarged    by   separating   the    fascial 
attachment  with  the  fingers.     Any  pockets  between 
the  tendons  or  muscles  are  widely  opened  by  the  pal- 
pating finger. 
27 


418 


INVOLVEMENT  OF  THE  FOREARM 


FIG.  124 


Cross-section  of  forearm  at  about  its  middle.  The  knife  is  seen  to  make 
an  incision  beyond  the  flexor  carpi  ulnaris  and  the  flexor  profundus,  which 
incision  should  be  made  for  pus  in  the  middle  of  the  forearm.  (See  Fig.  125.) 
Cotton  packed  in  the  opposing  surface  shows  the  position  of  pus. 


FIG    125 


Photographs  showing  the  proper  incisions  for  draining  abscesses  in  fore- 
arm. The  photograph  above  is  made  of  a  cadaver  arm  in  which  serial  sections 
were  made  and  the  proper  sites  for  striking  large  cavities  determined,  the 
artery  forceps  being  thrust  through  immediately  above  the  wrist,  and  an 
ulnar  incision  being  made  at  the  middle  of  the  forearm.  The  photograph 
below  shows  the  sites  of  these  two  ulnar  incisions. 


TREATMENT  OF   UNCOMPLICATED  CASES        419 

If  the  case  has  been  opened  late  and  the  pus  has 
infiltrated  the  forearm  extensively,  I  commonly  add 
an  incision  at  a  second  site  higher  up,  about  the  middle 
of  the  forearm.  Here  one  will  see  by  examining  the 
cross-section  (Figs.  120  and  124)  the  pus  tends  to  lie 
between  the  flexor  carpi  ulnaris  and  the  flexor  sublimis 
around  the  ulnar  artery  and  nerve.  Therefore  an  inci- 


FIG.  126 


Photograph  of  a  hand  of  a  patient  showing  proper  incisions  for  opening 
tendon-sheath  infections  of- the  thumb  and -little  finger,  with  ulnar  bursal 
extensions  of  pus  in  the  forearm.  This  patient  made  a  complete  recovery 
with  function  and  left  the  hospital  at  the  end  of  one  month.  Function  was 
complete  at  the  end  of  three  months. 

sion  is  made  about  one  inch  from  the  ulna  on  the  flexor 
surface  of  the  forearm,  attempting  to  strike  the  area 
between  these  two  muscular  bodies  (Figs.  124,  125, 
and  126).  The  opening  is  separated  widely  by  the 
forceps  and  fingers  after  the  skin  incision  is  made. 
Instead  of  this,  one  may  cut  down  directly  upon  the 
flexor  surface  of  the  ulna  and  separate  the  fibrous 


420 


INVOLVEMENT  OF  THE  FOREARM 


attachment  of  the  flexor  carpi  ulnaris  from  this  bone, 
and  in  this  manner  separate  the  muscle  from  the  flexor 
sublimis  and  profundus  and  thus  drain  the  pockets. 


FIG.  127 


Photograph  of  baby  G.'s  hand  and  forearm  three  days  after  incision  was 
made  for  the  drainage  of  an  ulnar  bursal  infection  with  extension  into  the 
forearm.  (See  Case  XLVI.) 

FIG.  128 


Result  three  months  after  (baby  G.),  showing  extension  and  flexion  of 
fingers.  Perfect  function  restored  except  for  two  distal  phalanges  of  the 
little  finger. 

These  are  all  the  incisions  that  in  my  experience  have 
been  necessary  to  produce  rapid  cure  in  these  cases. 


TREATMENT  OF  WRIST-JOINT  INVOLVEMENT    421 

One  should  use  care  not  to  cut  through  any  muscular 
body,  since  drainage  will  be  unsatisfactory.  The 
incisions  should  be  free  and  may  be  kept  open  from 
twenty-four  to  forty-eight  hours  by  gutta-percha 
strips  or  vaseline,  saturated  gauze.  Even  in  very 
young  individuals  this  treatment  is  most  satisfactory. 
My  youngest  case  of  ulnar  bursitis  and  forearm  in- 
volvement was  in  a  child  (Case  XLVI,  Figs.  127  and 
128),  whose  photographs  I  here  present. 

CASE  XLVI. — Wesley  Hospital.  The  child  was  three 
months  old  when  it  was  treated  and  six  months  old  when 
the  second  photographs  were  taken.  There  was  abso- 
lutely no  impairment  of  function  in  any  of  the  joints  or 
muscles  except  the  little  finger,  in  which  it  lost  the  power 
of  flexion,  as  will  be  seen  by  examining  the  photographs. 
Owing  to  the  age  of  the  patient  and  the  severity  of  the 
infection,  the  life  of  the  patient  was  despaired  of  by  the 
family  physician.  The  child  left  the  hospital  at  the  end 
of  the  eighth  day  after  the  above-described  incision  had 
been  made. 


TREATMENT  IN   CASES  WHERE   THE  WRIST-JOINT  IS 
INVOLVED. 

Besides  the  incisions  suggested  above  for  drainage 
of  the  forearm,  special  considerations  must  be  borne 
in  mind  when  dealing  with  involvement  of  the  carpal, 
carpometacarpal,  or  carporadial  articulations.  Owing 
to  the  frequently  associated  involvement  of  the  radial 
bursa,  this  will  generally  have  been  opened,  and  in 
serious  cases  the  necrotic  tendon  will  have  been  removed. 
The  fact  that  when  this  occurs  the  patient  is  generally 
of  advanced  age  will  emphasize  the  necessity  of  radical 
treatment  rather  than  temporizing  measures  which 
might  be  justifiable  in  younger  individuals.  This 
holds  true  not  alone  for  the  resection  of  the  tendon, 
but  also  as  regards  removal  of  the  carpal  bones.  In 


422  INVOLVEMENT  OF  THE  FOREARM 

every  one  of  the  several  cases  reported  above,  in  which 
the  joint  became  involved,  a  resection  of  some  or  all 
of  the  carpal  bones  was  indicated.  Even  in  younger 
individuals,  unless  prompt  and  radical  incisions  are 
made,  associated  with  careful  after-treatment,  unfor- 
tunate sequelae  are  likely  to  result.  That  it  does  not 
always  ensue  I  am  convinced  by  two  cases  which  came 
under  my  observation,  in  which  the  joint  made  a 
recovery  without  necrosis  of  the  bones,  but  here  prompt 
drainage  had  been  instituted.  However,  I  cannot 
speak  with  authority  upon  this  point,  since,  fortunately, 
my  own  experience  with  this  serious  sequela  has  been 
limited.  In  three  cases  it  became  necessary  to  remove 
necrotic  bone,  and  in  these  cases  a  complete  removal 
of  all  carpal  bones  was  found  advisable.  A  study  of 
the  anatomy  suggests  the  cause  of  the  tenacity  of 
this  infection  and  the  rapidity  with  which  it  involves 
the  entire  joint.  We  note  that,  as  described  by  Gray,1 
while  there  are  four  separate  synovial  sheaths,  yet 
in  reality  the  joint  proper  has  only  two,  and,  moreover, 
these  two  are  so  intimately  associated  that  the  least 
erosive  action  on  the  part  of  an  infection  lying  in  one 
would  cause  an  extension  to  the  other.  Moreover, 

1  Although  all  the  authors  agree  in  describing  the  radiocarpal  synovial  sac 
as  isolated  from  the  carpal,  there  is  great  variation  in  the  description  of  the 
carpal  sacs.  Cunningham  and  Quain  follow  Allen  Thompson,  and,  in  addition 
to  the  radiocarpal  and  cuneiform-pisiform,  describe  one  sac  between  the  semi- 
lunar  and  cuneiform  above  and  the  os  magnum  and  unciform  below,  another 
between  the  scaphoid  above  the  trapezium  and  trapezoid  below,  these  being 
separated  from  the  carpometacarpal  sac  below,  with  a  single  sac  between  the 
trapezium  and  thumb  metacarpal.  Gerrish  follows  Testut,  giving  the  same 
description  with  the  exception  that  he  divides  the  carpometacarpal  between 
the  middle  and  ring  metacarpals  into  two.  Joessel,  on  the  other  hand,  shows 
a  communication  between  the  carpal  and  the  metacarpocarpal  on  the  radial 
side,  with  a  separate  sac  for  the  metacarpocarpal  of  the  ring  and  little  finger 
metacarpals.  Gray  shows  a  general  communication  between  the  carpal  and 
metacarpocarpal.  This  difference  of  opinion  simply  demonstrates  that  the 
communications  vary  in  different  individuals.  In  a  surgical  consideration 
we  should  expect  a  more  or  less  free  communication,  consequently  in  this 
discussion  I  have  followed  Gray's  classification. 


TREATMENT  OF  WRIST-JOINT  INVOLVEMENT      423 

the  removal  of  any  of  the  more  important  carpal  bones 
in  the  radiocarpal  articulation  will  permit  of  immediate 
extension  in  the  synovial  spaces  about  the  distal 
bones,  as,  for  instance,  in  Case  XXX  we  read:  "Re- 
sected proximal  line  pf  carpal  bones,  later  distal  row 
of  carpal  bones  sloughed."  Consequently,  in  those 
cases  where  the  infection  is  confined  to  the  radiocarpal 
articulation  we  should  attempt  to  remove  the  carious 
bone  by  the  curette  and  give  perfect  drainage  to  the 
joint,  with  the  hope  of  preventing  extension  to  the 
carpal  synovial  sac.  The  probable  involvement  of 
the  radio-ulnar  synovial  sac  should  be  borne  in  mind, 
since  it  seems  to  be  a  frequent  complication.  The 
intimate  relation  of  the  ulnar  sheath,  as  already 
pointed  out,  results  in  early  and  extensive  involvement 
of  the  os  magnum  (Fig.  119). 

While  these  deductions  theoretically  are  true  and 
in  certain  cases  will  be  found  applicable,  in  the  majority 
of  cases  it  will  be  found  upon  operation  that  it  will 
be  necessary  to  remove  all  of  the  bones  of  the  carpus. 
The  ultimate  results  following  this  procedure  are 
much  better  than  one  would  think. 

When  the  carpal  synovial  sheath  is  involved,  how- 
ever, we  may  remove  any  of  the  carpal  bones  with  the 
exception  of  the  cuneiform,  semilunar,  or  scaphoid 
without  danger  of  causing  a  spread  to  the  radiocarpal 
joint. 

The  infection  of  the  synovial  sheath  between  the 
pisiform  and  cuneiform  may  spread  to  the  carpal 
articulation,  as  in  Case  XLII.  In  relation  to  which 
Forssell  quotes  from  Henle  to  the  effect  that  anatomic- 
ally there  is  frequently  a  communication  between  the 
two  sheaths. 

In  no  case  of  involvement  of  the  wrist-joint,  in  which 
the  diagnosis  was  delayed  three  weeks,  did  the  patient 
escape  without  the  removal  of  some  of  the  bones  of 


424  INVOLVEMENT  OF  THE  FOREARM 

the  joint.  In  other  words,  there  was  considerable 
erosion  of  the  bones  before  the  diagnosis  was  made. 
We  are  urged,  therefore,  to  watch  with  special  care 
aged  patients  with  involvement  of  the  radial  bursa  and 
to  open  the  joint  at  the  first  evidence  of  infection.  I 
am  convinced,  however,  that  this  complication  should 
be  a  rare  one  in  those  cases  submitted  to  early  and 
radical  treatment  for  infections  of  tendon  sheaths  and 
soft  parts.  In  each  of  the  five  cases  coming  under 
my  observation  the  sheath  had  not  been  opened  until 
long  after  the  infection  had  begun.  .Early  in  the 
course  of  joint  involvement  free  incision  will  give 
great  possibility  of  a  cure  without  the  necessity  for 
resection.  But  should  the  indication  arise  for  curettage 
or  removal  of  the  carpal  bones,  it  should  be  done 
thoroughly  and  completely  along  the  lines  suggested 
above. 

TREATMENT  IN  CASES  OF  SECONDARY  HEMORRHAGE. 

As  has  already  been  hinted  in  dealing  with  this  sub- 
ject, those  cases  showing  hemorrhage  should  not  be 
temporized  with.  As  soon  as  the  patient  has  recovered 
from  the  primary  shock  and  before  the  temporary 
tamponade  and  constriction  have  been  removed,  the 
surgeon  should  make  an  incision  over  the  ulnar  vessel. 
To  do  this  an  incision  should  be  made  about  the  middle 
of  the  forearm  on  the  ulnar  side,  as  described  above. 
The  flexor  carpi  ulnaris  is  then  drawn  to  the  ulnar 
side  and  the  artery  searched  for  (see  Fig.  122).  The 
site  of  the  hemorrhage  should  be  sought  and  the 
vessel  double  ligated  proximally  and  distally.  Tam- 
ponade and  clotting  cannot  be  depended  upon.  Further 
hemorrhages  are  almost  sure  to  occur  and  leave  the 
patient  in  such  serious  condition  that  he  may  not 
survive  the  combined  hemorrhage  and  infection. 


RESUME  425 


Subcutaneous  abscesses  should  be  opened  by  free 
incision. 

Deep  abscesses  in  the  forearm  are  best  treated  by 
making  incisions  directly  down  upon  the  ulna  an  inch 
and  a  half  up  on  the  forearm  cutting  the  fascial  attach- 
ments of  the  bone  and  freely  opening  up  the  inter- 
osseous  space  with  the  finger  inserted  between  the 
tendons  and  the  pronator  quadratus.  Counter  drain- 
age may  be  made  upon  the  radial  side  just  superficial 
to  the  radius.  The  ulnar  incision  particularly  should 
be  from  two  to  three  inches  in  length.  In  complicated 
cases  involving  the  whole  forearm  where  incision  has 
been  long  delayed,  it  may  be  necessary  to  make  an 
incision  two-thirds  of  the  way  up  on  the  forearm  on 
the  ulnar  side  between  the  flexor  carpi  ulnaris  and 
the  flexor  profundis.  This  incision,  however,  will 
seldom  be  required. 

When  the  wrist-  joint  is  involved,  prompt  drainage 
of  the  tendon  sheaths  may  end  in  recovery  ;  but  when 
treatment  has  been  delayed,  it  may  be  necessary  to 
remove  all  of  the  carpal  bone. 

In  cases  of  secondary  hemorrhage  the  vessels  should 
be  ligated  as  soon  as  the  patient  has  recovered  from 
the  primary  shock. 


CHAPTER  XXVIII. 
SEQUELS   OF    INFECTIONS    OF   THE   HAND. 

CHRONIC   PROCESSES,   OSTEOMYELITIS,  ARTHRITIS, 
CONTRACTURES,  AND  ATROPHY. 

IN  cases  showing  a  long-continued  suppuration,  we 
ask  ourselves  what  structures  are  involved  which  pro- 
long the  trouble,  or  why  we  have  inefficient  drainage. 
Frequently  both  factors  are  at  work.  By  far  the  most 
frequent  causes  are  osteomyelitis,  arthritis,  and  necrosis 
of  tendons. 

Areas  which  were  primarily  poorly  drained  cavities 
are  soon  complicated  by  one  of  these  factors.  Suppu- 
rative  arthritis  seldom  exists  without  concomitant 
osteomyelitis.  Such  cases  frequently  give  a  history 
of  primary  tenosynovitis,  followed  by  osteomyelitis, 
ending  in  arthritis. 

Involvement  of  the  wrist-joint  has  been  discussed 
in  the  previous  chapter. 

The  pathology  of  these  cases  naturally  varies  with 
the  tendency  of  the  tissues  to  react  to  the  particular 
germ  which  is  the  exciting  cause,  the  length  of  time 
the  process  has  existed,  and  the  structure  involved. 
Grossly  the  most  important  findings  are  the  sinuses, 
which  are  an  almost  constant  accompaniment  of 
chronic  disease.  Here  we  note  several  types,  and  while 
there  is  a  distinct  difference  between  them,  any  system 
of  classification  is  inadequate.  We  might  say  the 
osseous  and  connective-tissue  types,  or  the  acute,  sub- 
acute  and  chronic.  While  the  pathology  presents  some 
justification  for  either  system,  yet  the  reactive  resist- 


INVOLVEMENT  OF  THE  FINGER  PROPER        427 

ance  of  the  individual  and  the  kind  of  germ  enter  into 
the  subject  as  varying  factors;  consequently  only 
generalized  statements  can  be  made. 

The  chronic  osseous  type  presents  three  pictures, 
varying  with  the  bones  involved:  (i)  Those  cases 
where  the  terminal  phalanx  is  the  seat  of  osseous  de- 
struction; (2)  where  the  finger  proper  is  involved;  (3) 
where  the  metacarpal  and  carpal  bones  are  involved. 

INVOLVEMENT  OF  THE  FINGER  PROPER. 

Those  cases  (first  group)  showing  chronic  processes 
in  the  terminal  phalanx  have  already  been  discussed  in 
the  chapter  on  Felons  (Chapter  II). 

The  second  group  of  cases  noted  in  the  chronic 
osseous  type  is  that  which  comprises  suppurative  pro- 
cesses of  the  proximal  and  middle  phalanges.  We  all 
have  had  opportunity  to  observe  that  the  proximal 
interphalangeal  joint  particularly  may  become  involved 
early,  either  primarily  or  secondarily.  In  the  case  of 
the  metacarpophalangeal- joint,  however,  there  is  more 
fibrous  tissue  intervening  between  the  tendon  sheath 
and  the  joint  and  the  adjoining  bone;  therefore,  the 
sheath  erodes  through  at  some  less  resistant  point,  as, 
for  instance,  at  the  proximal  interphalangeal  joint,  in 
the  course  of  the  tendon  over  the  proximal  phalanx, 
or  at  its  proximal  end  in  the  palm  of  the  hand.  Fre- 
quently I  have  seen  a  sinus  lead  from  the  proximal 
end  of  the  sheath  of  a  tendon  through  the  palmar  fascia, 
and  the  metacarpophalangeal  joint  still  remain  intact 
(Fig.  119).  Again,  the  metacarpophalangeal  joint  is 
likely  to  escape  in  cases  of  palmar  abscesses  where  the 
diaphysis  of  the  metacarpal  has  become  involved,  or 
even  when  the  process  has  been  so  severe  as  to  extend 
under  the  annular  ligament  and  invade  the  carpal 
articulation.  It  has  been  my  experience  in  these  cases 


428        SEQUELA  OF  INFECTIONS  OF  THE  HAND 


that  the  distal  articulation  frequently  escapes  even  in 
long-continued  synovial  disease  and  extensive  osteo- 
myelitis. 

In  the  ordinary  case  of  chronic  suppuration  in  the 
finger  it  is  the  proximal  interphalangeal  joint  that  is 
at  fault,  and  the  pathological  condition  noted  in  Fig. 
130  is  fairly  typical.  The  constant  irritating  discharge 
coming  from  the  necrosing  bone,  passing  through  the 
connective  tissue  rich  in  lymphatics,  produces  an 
excessive  deposit  of  granulation  tissue,  building  up  a 

FIG.  129 


In  this  case  the  metacarpophalangeal  joint  was  intact,  although  the  tendon 
sheath  was  involved  and  a  sinus  had  opened  at  its  proximal  end  through 
the  palmar  fascia,  all  of  the  distal  and  part  of  the  middle  phalanx  had  been 
lost  and  the  proximal  interphalangeal  joint  was  extensively  destroyed. 

small  volcano-like  structure,  from  which  oozes  forth 
a  constant  stream  of  pus,  and  through  which  winds 
a  tortuous  canal  leading  down  to  the  necrotic  bone. 
Where  bone  alone  is  involved,  I  have  seen  this  crater 
clearly  defined,  occupying  no  greater  extent  than  the 
length  of  one  phalanx  and  raised  above  the  surface 
for  a  distance  half  the  diameter  of  the  finger.  This 
characteristic  picture,  however,  is  seldom  seen,  owing 
to  the  very  frequent  involvement  of  the  tendon  or 
the  joint  in  the  same  process.  Here,  while  the  devel- 


INVOLVEMENT  OF  THE  FINGER  PROPER        429 


opment   of   granulation    tissue   is   still   excessive,    the 
mouth  of  the  crater  is  generally  much  wider,  owing  to 

FIG.  130 


Drawing  from  pathological  section,  showing  sinus  leading  down  to  carious 
bone.  An  associated  tenosynovitis  has  increased  the  extent  of  the  granula- 
tion tissue  and  destroyed  in  part  the  typical  volcano-like  picture  of  an 
uncomplicated  palmar  bcne  sinus.  A,  ostium;  B,  intact  bone;  MP,  middle 
phalanx;  PP,  proximal  phalanx. 

FIG.  131 


Uncomplicated  bone  sinus  on  dorsum  of  phalanx. 

the  excessive  discharge  from  the  tendon  sheath.  The 
granulation  tissue  is  not  so  circumscribed,  although 
very  abundant.  Moreover,  the  picture  loses  some  of 


430        SEQUELAE  OF  INFECTIONS  OF  THE  HAND 

its  force,  owing  to  the  associated  swelling  of  the  finger 
along  the  tendon  sheath,  the  absence  of  which  in  the 
first  case  serves  to  accentuate  the  local  tumor  forma- 
tion. Again,  if  the  sinus  be  upon  the  dorsum  there  is 
less  granulation  formation,  owing  both  to  the  smaller 
amount  of  connective  tissue  and  probably  also  to  the 
great  reduction  in  the  number  of  lymphatics  (Fig.  131). 

FIG.  132 


Cross-section  through  the  joint,  showing  head  of  the  proximal  phalanx. 
Notice  the  large  amount  of  tissue  between  the  tendon  and  the  joint  cavity 
as  compared  to  Fig.  133. 

It  is  not  necessary  to  go  into  the  minute  pathology 
of  osseous  necrosis,  since  that  process  is  well  known 
and  described  in  the  ordinary  text-books.  However,  a 
few  details  peculiar  to  these  two  phalanges  should  be 
mentioned.  We  so  often  see  three  processes  in  con- 
junction, so  that  it  is  difficult  to  say  in  what  sequence 
they  developed — namely,  tenosynovitis,  arthritis  of 
the  proximal  interphalangeal  joint,  and  necrosis  of  the 
middle  phalanx.  The  cross-sections  here  presented 
(Figs.  132  and  133)  demonstrate  the  close  proximity 
of  the  tendon  sheath  to  the  bone  and  joint  respectively. 


INVOLVEMENT  OF  THE  FINGER  PROPER        431 

From  the  character  of  the  tissue  it  would  seem  reason- 
able to  assume  that  first  the  joint  is  involved,  and  the 
phalanx  sequentially.  In  the  few  early  cases  that  I 
have  been  able  to  observe  discriminatingly,  the  joint 
seemed  to  have  the  more  extensive  involvement  of  the 
two.  However,  if  that  be  true,  why  does  the  middle 
phalanx  suffer  so  much  more  than  the  proximal  one, 
a  fact  which  I  have  had  the  opportunity  to  verify 
frequently.  Is  it  that  the  point  of  invasion  is  the 

FIG.  133 


Cross-section  through  the  epiphysis  of  the  middle  phalanx.  Notice  the 
loose  mesh  and  the  small  amount  of  connective  tissue  between  the  tendon 
and  the  bone. 

epiphysis  of  the  middle  phalanx?  Does  the  fact  that 
that  phalanx  only  has  an  epiphysis  articulating  with 
the  joint  have  any  bearing  on  the  subject?  This 
question  must  be  left  for  further  study. 

Again,  destruction  of  the  epiphysis  is  frequently 
noted,  while  the  diaphysis-  is  only  partly  involved 
(Fig.  130).  The  anatomical  relation  of  the  sheath  of 
the  tendon  to  the  joint  capsule  and  the  epiphysis  may 
help  to  explain  this,  but  it  is  possible  that  the  vascular 
nature  of  the  epiphyseal  tissue  may  have  considerable 


432        SEQUELAE  OF  INFECTIONS  OF  THE  HAND 

bearing,  since  the  involvement  may  have  its  origin 
through  the  blood  supply  rather  than  by  direct  erosion. 
That  isolated  destruction  of  a  diaphysis  of  a  phalanx 
may  occur  at  times  cannot  be  questioned,  and  a  study 
of  the  cross-sections  demonstrates  how  easily  this  can 
occur  if  the  tendon  sheath  be  eroded. 

What  we  most  often  find  upcn  operation  in  these 
cases  is  a  suppurative  arthritis  with  extensive  destruc- 
tion of  both  the  epiphysis  and  shaft  of  the  middle 
phalanx,  while  the  proximal  surface  of  the  joint,  that 
is,  the  head  of  the  proximal  phalanx,  may  be  only 

FIG.  134 


Drawing  from  a  pathological  specimen,  showing  destruction  of  the  epi- 
physis of  the  middle  phalanx,  with  pinhead-sized  areas  of  the  necrosis  on  the 
head  of  the  proximal  phalanx.  MP,  middle  phalanx;  PP,  proximal  phalanx 

slightly  or  not  at  all  eroded  (Fig.  134);  at  least,  the 
articular  surface  is  still  clear  and  shining,  with  possibly 
one  or  two  minute  foci  of  destruction.  Frequently  it 
has  shown  a  larger  area  of  necrosis  upon  the  shaft 
just  at  the  point  where  the  ligaments  of  the  joint  are 
attached.  Indeed,  at  times,  either  upon  the  volar  or 
dorsal  surface,  varying  with  the  site  of  the  original 
infection,  I  have  scooped  out  at  this  site  an  area  the 
size  of  a  small  pea,  the  articular  surface  apparently 
being  free,  while  the  epiphysis  of  the  middle  phalanx 
was  almost  entirely  destroyed. 


INVOLVEMENT  OF  THE  FINGER  PROPER        433 

TREATMENT. — In  the  chronic  processes  involving  the 
finger  proper,  the  diagnosis  must  be  made  first  as  to  the 
structure  involved.  If  the  tendon  sheath,  it  must  be 
opened  throughout  its  extent  to  give  perfect  drainage. 
Frequently  it  will  be  necessary  to  remove  the  tendon 
in  these  chronic  cases.  The  possibility  of  localized  in- 
volvement must  always  be  borne  in  mind.  In  these 
cases  a  plastic  exudate  forms  and  prevents  extension 
along  a  sheath;  here  only  so  much  of  the  sheath  as 
has  been  involved  should  be  exposed.  If  the  joint  be 
invaded,  some  judgment  is  called  for,  since  in  the  very 
earliest  stages  it  may  recover  with  partial  restoration 
of  function  if  the  infection  is  a  mild  one,  the  joint 
surfaces  not  destroyed,  and  other  structures  which 
might  prolong  the  suppuration  are  uninvolved.  In 
a  great  majority  of  the  cases,  however,  considerable 
destruction  of  the  proximal  phalanx  will  have  taken 
place  when  the  case  comes  to  operation,  and  the  ques- 
tion arises  whether  an  amputation  should  be  advised. 
Certain  sociological  factors  come  into  consideration. 
If  the  patient  be  a  laboring  man,  with  a  family  depend- 
ent upon  him,  and  at  examination  we  find  an  extensive 
destruction  of  the  joint  with  a  tenosynovitis,  amputa- 
tion offers  the  quickest  method  of  giving  a  serviceable 
hand.  If,  however,  the  patient  desires  to  preserve  the 
finger,  in  a  majority  of  the  cases  one  can  be  assured 
that  the  finger  may  be  preserved,  but  that  it  will  be 
somewhat  shortened.  Exceptionally  the  finger  may 
be  preserved  with  considerable  function.  In  certain 
cases  it  becomes  imperative  to  make  the  attempt,  as, 
for  instance,  in  infections  of  the  thumb.  This  member 
is  so  valuable  that  some  sacrifice  is  justifiable  in  the 
attempt  to  preserve  it.  In  Case  XLVII,  quoted  below, 
the  articular  surfaces  and  a  considerable  portion  of  the 
shaft  of  the  proximal  phalanx  were  removed.  There 
was  no  involvement  of  the  tendon  sheath.  A  fairly 
28 


434        SEQUELA  OF  INFECTIONS  OF  THE  HAND 

serviceable  opposing  member  was  thus  saved  to  the 
hand. 

CASE  XLVII. — Primary  paronychia  of  thumb,  sec- 
ondary suppurative  arthritis  of  interphalangeal  joint, 
resection,  ultimate  recovery,  with  preservation  of  the 
thumb. 

C.  H.,  treated  in  the  Northwestern  University  Medical 
School  Dispensary,  May,  1902.  Infection  began  on  the 
thumb  under  the  nail  at  the  side  and  developed  into  a 
typical  "run-around."  When  he  applied  at  the  dispensary, 
four  weeks  after  the  beginning  of  the  infection,  a  chronic 
suppurative  arthritis  had  developed,  involving  the  inter- 

FIG.  135 


Photograph    showing   thumb   in   which   joint   has   been   resected.      Notice 
the  opposing  ability  of  the  member.      (Case  XLVII.) 

phalangeal  joint.  Under  narcosis  the  epiphysis  of  the 
distal  phalanx  and  about  half  of  the  distal  portion  of  the 
proximal  phalanx  were  found  partially  destroyed.  All  this 
involved  bone  was  removed  with  a  curette,  the  nail  was 
removed,  silkworm-gut  drain  inserted,  hot  boric  dressings 
applied.  The  tendon  sheath  of  the  flexor  longus  pollicis 
was  not  involved.  The  patient  returned  repeatedly 
for  dressings,  and  after  four  weeks  all  discharge  ceased. 
The  patient  was  discharged  with  the  thumb  shortened 
half  an  inch,  with  ability  to  flex  the  distal  phalanx  20 
degrees,  complete  function  in  the  metacarpophalangeal 
joint.  There  was  little  strength  to  the  flexion  of  the 
distal  phalanx,  but  it  served  admirably  as  an  opposing 
member  when  using  the  fingers  (Fig.  135). 


INVOLVEMENT  OF  THE  FINGER  PROPER        435 

The  procedure  when  the  proximal  interphalangeal 
joint  of  the  fingers  is  involved  is  as  follows:  Owing  to 
the  frequent  destruction  of  the  proximal  end  of  the 
middle  phalanx,  this  is  chosen  for  attack,  and  the  entire 
epiphysis  and  generally  about  half  of  the  shaft  is 
removed.  If  the  articular  surface  of  the  proximal 
phalanx  is  intact,  it  is  not  disturbed,  otherwise  this  may 
be  removed  also,  my  desire  being  in  the  first  place  to 
remove  all  necrotic  bone,  and  secondly,  to  separate  the 
ends  of  the  bone  so  far  that  only  a  fibrous  union  will 
take  place,  thus  allowing  some  motion  at  this  joint  if 
the  tendon  is  intact.  Otherwise  no  motion  can  be 
promised.  These  fingers  are  dressed  in  slight  flexion, 
so  that  if  no  function  results  they  will  not  be  in  the 
way  and  will  still  be  of  some  use,  at  least  for  cosmetic 
purposes.  In  some  cases  I  have  tried,  with  moderate 
success,  a  variety  of  extension  on  a  straight  splint. 
The  proximal  end  is  fastened  at  the  wrist,  and  at  the 
distal  end,  adhesive  straps  are  fastened  to  the  end  of  the 
splint  and  the  distal  portion  of  the  finger,  so  that  the 
ends  of  the  necrotic  bones  are  separated.  The  details 
of  this  mechanical  contrivance  may  be  seen  by  examin- 
ing Figs.  136  and  137.  This  aids  in  preserving  the 
functionating  joint,  although  it  is  somewhat  difficult 
to  retain  in  position.  Not  much  can  be  promised  in  the 
way  of  function  in  a  majority  of  cases.  That  in  excep- 
tional cases  these  fingers  can  be  saved  with  a  moderate 
amount  of  function,  even  in  some  cases  of  combined 
suppurative  arthritis  and  tenosynovitis,  is  demon- 
strated by  Case  XLVIII. 

CASE  XLVIII. — Limited  tenosynovitis  of  index  finger, 
arthritis  of  proximal  interphalangeal  joint,  osteomyelitis 
of  middle  phalanx,  resection  of  phalanx,  recovery,  with 
preservation  of  the  finger  and  slight  motion  at  the  joint. 

Miss  C.  W.  Seen  in  consultation  with  Dr.  C.  E. 
Boddinger.  Infection  had  begun  in  the  index  finger  by 


436        SEQUELA  OF  INFECTIONS  OF  THE  HAND 

a  prick  of  a  needle  while  sewing  two  weeks  previously,  and 
the  soft  parts  had  been  opened  over  the  middle  phalanx. 

FIG.  136 


A  photograph  of  a  finger  with  a  chronic  suppurative  arthritis  of  the  middle 
metacarpophalangeal  joint,  dressed  in  extension  produced  by  an  ordinary 
rubber  band  attached  to  the  end  of  the  finger  by  means  of  a  string  tied  to 
it  and  the  ends  fastened  through  the  eyes  of  a  button,  the  latter  being  attached 
to  the  finger  by  narrow  adhesive  strips  running  around  the  finger  up  to  the 
middle  metacarpophalangeal  joint — a  gauze  roller  around  the  adhesive 
strips.  Extension  is  secured  by  fastening  the  rubber  band  on  the  back  by 
a  piece  of  adhesive  plaster,  as  shown  in  Fig.  137.  The  board  splint  on  the 
palmar  surface  is  prevented  from  being  displaced  up  the  arm  or  laterally 
by  adhesive  strips  as  shown  in  the  figures.  It  is  a  modified  Buck's  extension. 
The  relief  from  discomfort  and  rapid  recovery  under  its  use  is  often  remarkable. 

Condition  upon  Examination. — Suppurative  tenosyno- 
vitis  of  the  index  tendon  extending  to  the  metacarpo- 
phalangeal articulation,  but  no  farther.  Tendon  exposed. 

FIG.  137 


See  FIG.  136. 

Suppurative  arthritis  of  the  proximal  interphalangeal  joint 
with  destruction  of  the  proximal  end  of  the  middle  phalanx, 
Distal  phalanx  not  involved,  articular  surface  slightly 
clouded,  but  not  eroded. 


INVOLVEMENT  OF  THE  HAND  PROPER          437 

Operation. — Tendon  sheath  opened  throughout  extent 
of  infected  area.  Middle  phalanx  resected  to  one-half 
its  extent.  Dorsal  counterincision  made  at  side  for 
thorough  drainage,  and  hot  boric  dressings  applied. 

Course. — After  three  weeks,  the  finger  had  entirely 
healed;  flexion  at  metacarpophalangeal  and  distal  pha- 
langeal  joints  perfect;  flexion  at  proximal  interphalangeal 
joint  15  degrees.  Six  months  after  operation  atrophy  of 
soft  tissues  of  distal  and  middle  phalanges.  The  patient 
states  that  the  finger  is  not  of  great  service,  but,  on  the 
other  hand,  is  not  in  the  way,  and  she  is  very  glad,  for 
cosmetic  reasons,  that  it  was  saved. 

Where  there  is  only  a  destruction  of  the  synovial 
covering  of  the  joint,  resection  is  not  indicated.  It  is 
probable  that  a  functionating  joint  can  be  restored  in 
case  of  ankylosis  if  the  tendon  sheath  is  not  involved, 
although  I  have  not  had  the  opportunity  to  demon- 
strate it.  If  the  destruction  of  the  adhesions  by 
repeated  flexion  of  the  finger  by  passive  motion, 
which  I  have  used  with  more  or  less  success  at  various 
times,  does  not  succeed,  the  implantation  of  periosteum 
from  the  tibia,  as  suggested  by  Hoffman,1  is  worthy 
of  consideration,  or  the  transplantation  of  a  pad  of 
tissue  and  fat  such  as  I  have  used  in  the  wrist-joint 
may  be  used  with  satisfaction. 

Suppuration  is  uncommon  in  the  metacarpophalan- 
geal joint,  but  here  also  resection  may  be  resorted 
to  if  the  tendon  is  intact.  If  this  be  involved,  in  a 
majority  of  cases,  I,  at  the  present  time,  would  ampu- 
tate the  finger. 


INVOLVEMENT  OF  THE  HAND  PROPER  AND  THE  META- 
CARPALS  AND  CARPALS. 

PATHOLOGY. — The    third    type    of    chronic    osseous 
lesion  is  that  in  which  the  bones  of  the  hand  proper 

1  Arch.  f.  klin.  Chir.,  vol.  Ixxx,  No.  2,  p.  31 1 ;  Zur  Behandlung  der  knachernen 
Ankylose  in  Elbogengelenk. 


438        SEQUELAE  OF  INFECTIONS  OF  THE  HAND 


are  involved.  Here,  unless  modified  by  an  original 
wound  or  operative  procedure,  the  picture  is  again 
different,  owing  to  the  dense  aponeurosis  upon  the 
palmar  side  and  the  sheet  of  dense  tissue  upon  the 
dorsum  uniting  the  tendons  of  the  extensor  communis 
digitorum.  These  dense  sheets,  particularly  upon  the 


FIG.  138 


Skin. 


Lumbrical  muscle  in 
middle  palmar  space. 


Palmar  arch.  - 

Blood  vessel. 

Lumbrical  muscle 

and   tendon. 

Median  nerve  and  vessels. 

Flexor  lonyus  pollicis. 

Thmiar  muscles. 


Blood  vessels. 
Point  of  exit  of  pus. 

nterosseons  muxcle 
spread  over  bone. 

Epiphysis  of  bone. 
Subcutaneous  space. 
Subaponeurotic  space. 

Bone. 

Interoasei  separated 
by  fancinl  septum. 
Extensor  communis 
tendon. 

Middle  palmar  space 
'  filled  with  pus. 

Skin. 
Metacarpals. 


Radial  artery. 


Drawing  showing  the  relation  of  pus  in  the  middle  palmar  space  to  the 
tendons.  Also  showing  course  pus  pursues  in  its  course  along  the  lumbrical 
muscle  to  point  on  the  dorsum  near  the  web.  Serial  sections  of  the  hand 
were  made  as  shown,  the  tissues  teased  out,  and  middle  palmar  space  filled 
with  plaster  of  Paris.  Sections  restored  to  normal  position  and  sagittal 
section  made  between  ring  and  middle  metacarpal  of  all  sections  except 
the  proximal.  Heavy  dotted  area  shows  position  pus  would  occupy. 

palm,  prevent  the  free  egress  of  pus,  and,  as  a  conse- 
quence, it  is  more  likely  to  burrow  a  considerable  dis- 
tance from  the  site  of  origin  before  exit  (Fig.  138). 
This  diffuses  the  reactive  inflammation,  and  even  if 
the  exit  is  found  near  the  site,  the  dense  sheet  prevents 
the  crater-like  elevation  of  granulation  tissue  noted 
in  the  second  or  phalangeal  type.  Hence,  we  are  more 


INVOLVEMENT  OP  THE  HAND  PROPER          439 

likely  to  find  a  diffuse  swelling  of  the  whole  palm  or 
dorsum  with  multiple  ostia,  any  of  which  may  be  open 


FIG.  139 


DSCS 


IDSAS 


15 


PF 


ITS 


FLP 


T5 


Schematic  drawing,  showing  pus  under  dorsal  aponeurosis  with  ostium 
at  the  side:  C,  site  of  discharge  of  pus;  DP  A,  deep  palmar  arch;  DSCS,  dorsal 
subcutaneous  space;  FLP,  flexor  longus  pollicis;  IDS  AS,  infected  dorsal 
subaponeurotic  space;  IS,  indefinite  spate;  ITS,  indefinite  thenar  space;  LM, 
lumbrical  muscle;  MPS,  middle  palmar  space;  OM,  osteitis  of  the  meta- 
carpal;  PF,  palmar  fascia;  TS,  thenar  space. 

for  a  time  and  discharge,  while  another  may  be  closed. 
There  is  often   only  a  small   amount  of  granulation 

FIG.  140 


Drawing  of  fragments  of  metacarpal  removed  by  Dr.  W.  E.  Schroeder. 

tissue  about   the   openings.      In   these   cases  of  early 
osseous  involvement  often  no  sinus  will  appear  upon 


440        SEQUELM  OF  INFECTIONS  OF  THE  HAND 

the  palmar  surface,  unless  the  soft  tissues  of  the  palm 
have  been  seriously  involved  primarily,  or  the  infection 
has  spread  into  the  wrist-joint,  and  this  is  generally 
preceded  by  palmar  phlegmon  or  tenosynovitis.  There- 
fore, in  these  cases  of  osteomyelitis  of  the  metacarpal 
bones,  dorsal  sinuses  are  most  common.  They  may 
appear  at  any  point  on  the  dorsum,  but  have  a  pre- 
dilection for  the  sides  and  distal  part  near  the  knuckles 
(Fig.  139),  owing  to  the  dense  sheet  of  tissue  before 
mentioned.  It  is  a  well-known  fact,  however,  that  fre- 
quently this  sheet  has  areas  where  it  is  not  complete, 
particularly  in  the  lower  third  between  the  tendons; 
and  through  these  pus  may  discharge.  But  it  is  not 
at  all  an  uncommon  thing  to  see  a  sinus  ostium  at  either 
side  over  the  index  and  little  finger  metacarpal,  and  one 
or  two  at  the  distal  end  between  the  knuckles,  from 
a  single  focus  of  infection  in  either  the  middle  or  ring 
metacarpal  (Fig.  64),  as  will  be  shown  clearly  by  x-ray 
picture.  Again,  these  ostia  on  the  dorsum  at  the 
knuckles  may  be  due  to  a  chronic  process  in  the 
palm  discharging  through  the  lumbrical  canals  (see 
Fig.  138). 

So  fas  as  I  have  observed,  there  is  no  peculiar 
pathological  destruction  of  the  metacarpal  bones  in 
these  cases  (Fig.  140).  There  is  one  clinical  fact,  how- 
ever, worth  remembering  from  a  therapeutic  stand- 
point, and  that  is  the  relative  immunity  from  involve- 
ment of  the  metacarpophalangeal  joint;  this  is  possibly 
owing  to  the  dense  ligaments  surrounding  the  joint, 
which  protect  it  from  invasion  by  way  of  the  synovial 
sheath  and  adjacent  phlegmons.  As  a  consequence  of 
this  we  are  often  able  to  preserve  a  functionating  finger, 
although  a  considerable  destruction  of  the  metacarpal 
may  be  present;  isolated  necrosis  of  a  metacarpal  is 
uncommon  except  in  tuberculosis  or  syphilis. 


PIG.  141 


•X-ray  photograph  of  hand  (Case  XLIX).  Necrotic  bone  was  removed 
from  the  wrist  and  the  three  metacarpals.  (See  photograph  of  hand  shewing 
present  function,  Fig.  142.) 


442        SEQUELA  OF  INFECTIONS  OF  THE  HAND 

Involvement  of  the  wrist-joint  in  chronic  processes 
is  characterized  by  multiple  foci  on  both  the  dorsal 
and  palmar  surface. 

CASE  XLIX. — S.,  Post-Graduate  Hospital,  December, 
1910.  The  patient  suffered  from  a  previous  tendon- 
sheath  infection  of  the  ulnar  and  radial  sheaths.  I  saw 
him  after  three  months  of  chronic  infection,  when  there 
were  multiple  sinuses  both  on  the  dorsum  and  flexor 

FIG.  142 


Hand  of  patient  described  in  Case  XLIX  two  years  after  operation. 

surface  of  the  wrist  from  the  joint,  with  lateral  and  distal 
sinuses  upon  the  dorsum  of  the  hand  from  osteomyelitis 
of  the  metacarpals  of  the  index,  middle,  and  little  fingers. 
There  was  no  involvement  of  the  metacarpophalangeal 
articulations,  in  spite  of  the  long-continued  infection  and 
extensive  osteomyelitis.  The  x-ray  picture  clearly  showed 
the  location  of  the  foci.  All  of  the  carpal  bones  were 
removed  and  the  necrotic  part  of  the  metacarpals.  The 


INVOLVEMENT  OF  THE  HAND  PROPER          443 

hand    rapidly    recovered.      All    discharge    ceased    within 
four  weeks.     Almost  all  function  was  lost.     (Fig.  141.) 

I  have  been  surprised  to  find  that  now  after  two 
years  he  has  developed  considerable  function  of  the 
fingers  and  hand,  so  that  he  can  now  hold  a  glass  and 
perform  other  gross  functions  with  the  hand  as  well  as 
write,  hold  a  knife  and  fork,  and  similar  actions  (Fig. 
142).  I  have  had  a  similar  experience  in  two  other 
cases. 

The  following  history  of  a  patient  in  the  practice  of 
Dr.  H.  B.  Baumgarth,  with  whom  I  saw  the  case  in 
consultation,  illustrates  the  course  of  these  chronic 
cases  when  untreated. 

CASE  L. — Mrs.  G.  received  infection  September  5, 
1904,  at  web  between  the  middle  and  ring  fingers.  The 
patient  consulted  a  magnetic  healer  and  remained  under 
his  care  for  seven  weeks,  when  she  applied  to  Dr.  Baum- 
garth, who  obtained  the  following  history  and  drained 
the  hand  properly:  Twenty-one  days  after  the  receipt  of 
the  infection,  point  2,  noticed  on  the  dorsum,  opened  up; 
a  few  days  later,  points  3  and  4  opened,  slightly  more  on 
the  dorsal  surface  than  on  the  palmar.  Points  5,  6,  7, 
and  8  appeared  successively  in  the  next  few  days.  After 
an  interval  of  a  few  days,  points  9  and  10  appeared, 
followed  in  succession  by  12  and  13,  and  after  an  interval 
of  several  days,  14,  15,  and  16,  at  which  time  the  patient 
applied  to  Dr.  Baumgarth,  who  thoroughly  drained  the 
pockets,  and  the  patient  made  a  tardy  recovery.  The 
atrophy  of  the  distal  phalanx  of  the  index  finger  is  due 
to  a  previous  felon.  The  atrophy  of  the  other  fingers 
followed  as  a  sequence  of  the  present  infection. 

On  February  25  adhesions  were  broken  up  under  nitrous 
oxide,  which  benefited  the  movement  of  the  finger  and 
wrist  to  a  slight  extent  only. 

A  careful  study  of  this  case  serves  to  point  out  the 
pathological  sequence  which  occurred  as  a  result  of  the 
infection  (Fig.  143).  Points  I  and  2  were  the  original 


444        SEQUELA  OF  INFECTIONS  OF  THE  HAND 

site  of  the  infection,  which  spread  from  there,  without 
doubt  by  lymphatic  extension  or  continuity  of  tissue, 
along  the  lumbrical  canal  into  the  mid  palmar  space; 
from  here  in  turn  it  retraced  its  course  through  the 
lumbrical  canals  to  the  base  of  the  index  finger,  point  4, 
and  the  base  of  the  little  finger,  point  6.  The  ulnar 
bursa  evidently  became  involved,  and  points  9  arid  10 

FIG.  143 


Photograph  of  Dr.  Baumgarth's  case.  Figure  numbers  on  the  photograph 
represent  the  various  sinuses  and  their  approximate  order  of  development 
by  which  the  course  of  the  infection  can  be  traced.  (See  Case  L.) 

show  the  site  of  rupture  from  the  sheath,  the  other 
areas  at  the  base  of  the  palm  developing  as  a  rupture 
of  the  proximal  end  of  this  bursa.  This  point  was 
corroborated  by  Dr.  Baumgarth  at  the  time  of  opera- 
tion, since  pus  was  found  above  the  annular  ligament 
in  this  synovial  sac.  It  is  to  be  noted  that  all  the 
primary  points  of  rupture  from  I  to  8  appeared  upon 
the  dorsal  surface  of  the  base  of  the  webs  of  the  fingers. 


INVOLVEMENT  OF  THE  HAND  PROPER          *445 

The  characteristic  claw-hand  seen  in  neglected  tendon- 
sheath  infection  is  shown  in  Fig.  144. 

In  those  exceptional  cases  in  which  the  pus  has 
extended  to  the  dorsum  between  the  metacarpal  bones, 
there  is  generally  some  destruction  of  bone  requiring 
attention.  It  is  at  times  seen  in  advanced  cases 
accompanying  wrist-joint  invasion. 


FIG.  144 


Photograph  showing  claw-hand  in  neglected  tendon-sheath  infection. 

TREATMENT  OF  CASES  INVOLVING  THE  HAND  PROPER. 
—The  treatment  in  those  cases  in  which  the  chronic 
process  lies  in- the  palm  may  be  confusing.  We  should 
determine  first  the  location  of  the  pus.  Does  it  lie  in 
the  synovial  sheaths  or  in  the  fascial  space?  Are  the 
bones  or  the  wrist-joint  involved?  While  theoretically 
difficult  to  determine,  it  is  not  so  confusing  as  in  the 
acute  cases,  since  there  are  generally  sinuses  which  can 
be  followed  down  to  the  hidden  pockets.  X-ray  photo- 
graphs may  show  necrotic  bone.  Complete  anesthesia 
is  essential.  No  operation  upon  infected  hands  should 
be  undertaken  without  it.  The  ramifications  should 


446        SEQUELAE  OF  INFECTIONS  OF  THE  HAND 

be  followed  up  carefully  and  with  patience.  I  shall  not 
speak  in  detail  of  the  factors  which  lead  us  to  diag- 
nosticate the  presence  of  pus  in  the  various  sites, 
since  this  has  already  been  discussed  exhaustively  in 
the  previous  chapters. 

Various  sinuses  leading  from  the  tendons  to  the  sur- 
face will  be  followed  down  to  the  respective  synovial 
sheaths.  The  sinuses  found  at  the  most  proximal 
point  of  the  finger  sheaths  designate  the  corresponding 
sheath,  and  this  should  be  cut  down  upon  and  followed 
distally  along  the  finger  until  every  part  of  the  tendon 
bathed  in  pus  is  exposed.  Where  the  little  finger 
tendon  is  involved,  the  extension  of  the  sheath  in  the 
palm  should  be  borne  in  mind,  and  the  opening  con- 
tinued proximally  over  this  when  the  grooved  director 
inserted  into  the  infected  sheath  on  the  little  finger 
passes  up  into  this  without  obstruction.  Here  the 
sheath  should  be  opened  throughout  its  extent  up  to 
the  annular  ligament,  the  incision  lying  to  the  ulnar 
side  of  the  tendons.  The  incision  should  be  limited  to 
the  annular  ligament  until  the  decision  has  been  made 
as  to  whether  the  infection  has  extended  under  this 
into  the  proximal  end  of  the  sheath  above  the  annular 
ligament.  If  this  is  diagnosticated,  the  ligament  should 
be  cut  and  the  incision  be  continued  into  the  forearm 
as  far  as  the  upper  end  of  the  sheath.  Instead  of  this 
last  incision  the  upper  end  of  the  sheath  may  be  drained 
by  incisions  upon  the  ulnar  and  radial  side  of  the 
forearm  as  described  in  the  chapter  on  Forearm  In- 
volvement. It  is  not  wise  to  open  the  sheath  above 
and  below  the  ligament  and  leave  this  latter  intact. 
Having  thoroughly  opened  this,  the  question  thus 
arises:  Has  the  radial  bursa,  i.  e.,  the  sheath  cf  the 
flexor  longus  pollicis,  become  involved?  If  so,  this 
must  be  opened  throughout  its  extent  down  to  a 
thumb's  breadth,  distal  to  the  annular  ligament.  The 


INVOLVEMENT  OF  THE  HAND  PROPER 


447 


incision  should  stop  here  for  fear  of  injuring  the  motor 
nerve  to  the  thenar  area. 

If  the  tendons  have  become  necrotic,  removal  is 
indicated;  on  the  other  hand,  one  is  often  surprised  at 
the  amount  of  vitality  present  in  the  tendons  which 
have  lost  their  synovial  covering,  therefore  after  open- 
ing a  sheath  considerable  conservatism  is  justifiable 
when  it  comes  to  a  question  of  preserving  or  removing 
a  tendon.  Some  of  the  chronic  sluggish  processes  in 
the  fingers  have  seemed  to  be  benefited  by  the  Klapp 
suction  cup  (Fig.  145). 


FIG.  145 


Showing  Klapp 's  aspiration  cup  used  in  some  old  chronic  infections  of  the 

fingers. 

If  the  fascial  spaces  are  involved,  they  should  be 
drained  after  the  methods  described  in  Chapter  XVII. 

In  considering  the  treatment  of  those  cases  in  which 
the  suppurating  ostia  appear  upon  the  dorsum,  par- 
ticularly between  the  knuckles,  I  have  already  pointed 
out  that  in  a  majority  of  cases  these  are  really  sinuses 
leading  from  the  palm  along  the  lumbrical  canals 
(Fig.  138),  and  the  perfect  drainage  of  the  palm  along 
the  lumbrical  canals,  as  already  mentioned,  will  end 
in  rapid  recovery  if  uncomplicated  by  tendon  or  bone 
involvement. 


448        SEQUELA  OF  INFECTIONS  OF  THE  HAND 

If  the  bones  of  the  hand  or  wrist  are  involved,  they 
should  be  removed  or  the  necrotic  part  curetted  out. 
In  treating  the  wrist-joint  the  general  principles  as  to 
the  removal  of  bones,  which  have  been  enunciated  in 
Chapter  XXVII,  when  dealing  with  carpal  involve- 
ment, should  be  borne  in  mind.  These  should  not, 
however,  interfere  with  the  paramount  rule  that  all 
dead  bone  should  be  removed. 


ATROPHY  AND   CONTRACTURE. 

The  anatomical  and  clinical  evidence  already  adduced 
shows  the  tendency  for  the  infection  to  extend  in 
juxtaposition  to  the  bloodvessels  and  nerves.  The 
former  leads  to  contracture  about  the  veins  and  lym- 
phatics, and  consequently  a  persisting  distal  edema. 
The  most  serious  sequelae,  however,  ensue  because  of 
the  extension  along  the  nerves — metacarpal,  ulnar,  and 
median — leading  secondarily  to  trophic  changes  in  the 
part.  This  secondary  change  follows  probably  upon 
contraction  of  the  scar  tissue  about  the  nerves,  since 
they  are  not  likely  to  be  destroyed  by  the  process. 
At  times  we  see  the  median  nerve  persisting,  partly 
isolated  from  the  surrounding  tissue,  although  in  con- 
junction with  the  tendons  it  may  be  destroyed  at  the 
wrist-joint  from  pressure  necrosis  by  the  non-distensible 
annular  ligament. 

This  secondary  change  is  particularly  noticeable  in 
the  claw-hand  and  the  atrophy  of  the  distal  phalanges, 
and  even  of  the  whole  hand  (Fig.  143  and  144).  This 
sequela  of  nutritive  and  trophic  disturbance  yields 
slowly  or  not  at  all  to  the  restorative  processes  of  nature. 
Massage,  passive  motion,  and  constant  use  of  the  hand 
carried  out  systematically  under  the  careful  personal 
supervision  of  the  surgeon  will  aid  nature.  Adhesions 
between  the  joints,  when  they  are  not  the  result  of 


ATROPHY  AND  CONTRACTURE  449 

the  destruction  of  the  synovial  coverings,  may  be 
treated  by  repeated  non-violent  passive  movements 
under  nitrous  oxide  anesthesia,  or  by  the  various 
appliances  designed  to  produce  passive  motion,  par- 
ticularly those  which  act  by  exhausting  the  air,  and 
hence,  in  addition  to  producing  mobility,  favor  active 
congestion  of  the  parts  (Figs.  96  and  97). 

The  amount  of  function  secured  by  these  hands, 
apparently  irretrievably  injured  by  scar  tissue  and 
destruction  of  nerves  and  tendons,  is  above  expecta- 
tion if  treatment  such  as  suggested  above  is  persist- 
ently carried  out.  Unfortunately  very  few  patients 
will  continue  their  treatment  day  after  day  for  two 
or  three  years.  But  even  under  the  best  circum- 
stances the  most  delicate  functions  of  the  hand  are 
frequently  lost.  The  claw-hand  is  likely  to  persist 
and  ankylosed  joints  add  materially  to  the  impair- 
ment of  function.  I  have  constantly  sought  for  some 
surgical  procedure  which  might  offer  some  hope  of 
restoring  function  in  these  cases.  In  several  instances 
I  have  dissected  out  the  tendons  on  the  flexor  and 
extensor  surfaces  and  tried  various  procedures,  and 
while  I  am  not  ready,  as  yet,  to  offer  much  encour- 
agement, my  best  results  have  been  obtained  by  the 
transplantation  of  pads  of  fat  around  the  tendons. 
At  a  subsequent  period,  after  further  observation 
of  cases  already  operated  upon  and  others  that  may 
come  under  my  care,  it  is  possible  that  a  technique 
may  be  developed  that  will  offer  some  hope,  at  least, 
in  these  most  lamentable  cases. 

Where  the  tendon  is  involved  in  the  synovial  sheath 
of  the  finger,  I  have  so  far  been  able  to  do  little. 

Where  the  involvement  is  upon  the  dorsum  or  in  the 
palm,  some  results  have  been  obtained. 

The  involvement  of  the  wrist-joint  with  ankylosis 
has  been  successfully  treated  by  the  removal  of  the 
29 


450        SEQUELA  OF  INFECTIONS  OF  THE  HAND 

carpal  bones  and  the  transplantation  of  free  flaps  of 
fat  or  fat  and  fascia  into  the  joint,  although  these 
cases  also  have  not  been  observed  long  enough  to 
present  the  maximum  of  benefit  or  develop  an  absolute 
technique.  Whether  the  incision  is  made  upon  the 
radial  or  ulnar  side,  or  both,  of  the  dorsum,  the  bones 
are  chiseled  or  curetted  away,  the  contour  of  the  joint 
is  restored,  and  free  flaps  of  fat  from  the  leg  with  fascia 
are  transplanted  into  the  joint.  In  no  case  has  the 
transplant  been  lost  by  infection  or  necrosis,  and  in 
every  case  a  considerable  degree  of  function  has  been 
restored.  In  addition  to  this  the  function  of  the  fingers 
has  been  improved  by  the  shortening  of  the  forearm. 
I  herewith  present  the  photograph  of  one  case  recently 
operated  upon. 

CASE  LI. — Mr.  E.  History:  The  patient's  arm  was 
crushed  between  the  couplings  of  a  railroad  train.  Fol- 
lowing this  a  severe  infection  ensued  in  the  hand  and  fore- 
arm in  which  apparently  both  the  ulnar  and  radial  bursae 
were  involved  and  there  was  a  destruction  of  nerves  and 
tissue  at  the  time  of  injury  which  was  subsequently 
followed  by  sloughing  of  the  ulnar  nerve.  The  ultimate 
result  presented  at  the  time  he  came  under  my  observa- 
tion, two  years  after  the  injury,  was  that  of  a  claw-hand 
with  sharp  flexion  at  the  wrist  and  ankylosis  of  the  wrist- 
joint  with  adhesions  about  the  tendons  and  scar  tissue 
and  contracture  on  the  flexor  surface  of  the  forearm. 

Operation. — The  scar  tissue  along  the  flexor  surface 
was  dissected  out,  the  ulnar  nerve  was  sought  for  and 
could  not  be  found,  owing  to  its  loss  from  previous  destruc- 
tion. The  median  nerve  was  isolated  from  the  scar  tissue 
of  the  forearm,  and  as  far  as  possible  the  tendons  were 
removed  from  the  scar  tissue.  Incision  was  made  on  the 
dorsal  surface  on  the  radial  side  and  the  carpal  bones 
removed.  A  flap  of  fat  was  transplanted  from  the  leg 
into  the  joint  and  the  wound  closed.  Owing  to  scar 
tissue  on  the  back  and  buttocks,  it  was  deemed  advisable 
to  secure  skin  and  fat  for  the  restoration  of  the  flexor 
surface  from  the  upper  portion  of  the  abdomen.  Here 


ATROPHY  AND  'CONTRACTURE  451 


ur 

FIG.  146 


Case  LI,  before  operation,  showing  full  amount  of  flexion  and  extension. 
Note  that  the  thumb  cannot  be  adducted  to  meet  any  of  the  fingers. 


PIG.  147 


Case  LI,  two  months  after  operation. 


452        SEOUEfcE^QP,  A&KECTIONS  OF  THE  HAND 

a  semi  lunar  flap  of  skin  and  subcutaneous  tissue  was 
dissected  out  with  its  base  downward.  The  fat  was  dis- 
sected off  from  the  flap  for  a  considerable  portion  of  its 
surface.  The  skin  was  then  attached  to  the  forearm  on 
its  ulnar  side  and  the  flap  of  fat,  still  attached  to  the  skin 
at  its  base,  was  wrapped  around  the  median  nerve  and 
sutured  in  position.  By  repeated  incisions  and  suturing 
the  skin  flap  was  completely  attached  at  the  end  of  twelve 
days  and  the  hand  made  an  immediate  recovery.  Ultimate 
function  cannot  as  yet  be  determined,  but  the  immediate 
result  is  shown  by  the  picture.  The  patient  now  has  a 
functionating  hand  with  which  he  can  feed  himself,  can 
write,  adjust  his  tie,  drive  a  horse,  and  do  other  gross  func- 
tions. The  patient  is  entirely  satisfied  with  the  result,  but 
I  am  sure  as  the  months  go  by  much  greater  function  will 
be  secured,  both  by  the  wrist,  which  now  has  45  degrees  of 
flexion  and  on  the  part  of  the  fingers  which  though  much 
improved  still  contract.  We  cannot  expect  complete 
restoration  of  function  owing  to  the  scar  tissue  in  the 
sheaths. 

This  is  but  one  of  several  cases  now  under  observa- 
tion. A  later  contribution  will  detail  in  full  the  final 
results. 

Experimental  investigations  as  to  the  restoration  of 
destroyed  tendons  have  been  carried  out,  but  as  yet 
nothing  definite  can  be  recommended  in  cases  of  loss 
of  finger  tendons,  although  something  may  be  hoped 
for  in  the  future.  Where  the  tendon  is  outside  of  its 
bursal  sheath  it  can  be  restored  by  the  transplantation 
of  free  fascial  flap,  as  has  been  shown  by  Lewis  and 
Davis  and  others. 

Experience  has  taught  me  that  scientifically  made 
incisions  based  upon  the  anatomy  herein  pointed 
out  will  provide  complete  drainage  of  all  the  pockets, 
and  in  the  end  will  give  a  much  more  serviceable 
hand  than  we  have  had  the  fortune  to  secure  in  the 
past.  It  cannot  be  urged  too  strongly  that  we  should 
make  careful  study  as  to  the  possible  position  of  pus 


RESUME— CHRONIC  INFECTIONS  453 

in  the  hand,  to  the  end  that  we  may  make  early  and 
radical  incisions  and  thus  prevent  these  cases  of  atrophy 
and  contracture. 


RESUME— CHRONIC  INFECTIONS. 

Necrosis  of  the  distal  phalanx  ordinarily  ends  in 
sloughing  of  the  diaphysis  alone.  Joint  function  should 
be  preserved.  Incision  should  be  made  laterally  in- 
stead of  upon  the  volar  surface.  (See  Chapter  I.) 

The  proximal  interphalangeal  joint  is  most  commonly 
involved.  The  proximal  phalanx  excapes  while  the 
epiphysis  and  part  of  the  diaphysis  of  the  middle 
phalanx  are  destroyed. 

Conservative  operations  may  be  done  with  some 
success. 

Isolated  involvement  of  the  tendon  sheaths  may 
be  present.  Incision  of  the  sheath  should  expose  all 
involved  parts. 

Chronic  palmar  abscesses  frequently  point  on  the 
dorsum,  passing  along  the  lumbrical  canals.  Palmar 
abscesses  may  be  opened  along  these  canals. 

Chronic  dorsal  abscesses  may  point  at  a  distance 
from  the  focus,  owing  to  the  dorsal  aponeurotic  sheet. 

The  carpal  joints  are  frequently  invaded  from  the 
radial  bursa;  abscesses  and  sinuses  appear  upon  the 
dorsum,  as  well  as  upon  the  flexor  surface.  It  will 
generally  be  necessary  in  these  cases  to  remove  all 
of  the  carpal  bones.  (See  Chapter  XXVII.) 

Serious  forearm  abscesses  lie  dorsal  to  the  flexor 
profundus  digitorum,  and  should  be  opened  by  lateral 
drainage. 

Trophic  changes  result  from  the  tendency  of  the 
pus  to  extend  along  the  nerves  and  bloodvessels. 


454        SEQUELM  OF  INFECTIONS  OF  THE  HAND 

Complete  function  can  be  promised  patients  suffer- 
ing with  palmar  abscesses  uncomplicated  by  tendon- 
sheath  or  osseous  infection. 

Tendon-sheath  infections  operated  upon  early  give 
good  function,  except  that  flexion  of  the  two  distal 
phalanges  may  be  lost. 

In  ankylosis  of  the  joints,  considerable  improvement 
may  be  secured  by  a  transplant  of  fat  and  fascia  into 
the  joint. 


INDEX 


ABSCESS,  collar-button,  52 
treatment  of,  55 

in  course  of  lymphatic  vessel,  327 
deep,  of  forearm,  396 
distal  palmar,  52 
of  fascial  spaces,  after-treatment 

of,  304 

treatment  of,  289 
of  forearm,  treatment  of,  416 
localized,  55 

hypothenar  space,  55 
thenar  space,  55 
location  of,  in  forearm,  397 
of   middle   palmar   space,   treat- 
ment of,  290 

periglandular,  treatment  of,  373 
of  radial  lymphatics,  175 
shirt-stud,  52 
subaponeurotic  space,  treatment 

of,  303 

subclavicular  and  shoulder,  treat- 
ment of,  373 

subcutaneous,  in  forearm,  395 
treatment   of,    in   lymphan- 
gitis, 372 
subepithelial,  37 
thenar  space,  treatment  of,  301 
Absorption  of  virulent  toxins,  preven- 
tion of,  259 

Adhesions,  prevention  of,  303 
in  tenosynovitis,  206 

prevention  of,  286 
treatment  of,  Bier's,  288 
Alcohol  dressings,  257 
Anatomy,  cross-section,  distal  to  web, 

84 
one-half  centimeter  proximal 

to  the  joint,  87 
taken  at  wrist,  97 
three  centimeters 

above  joint,  90 
through  base  of 

palm,  94 
distal      part      of 
thenar        emi- 
nence, 92 
epiphysis  of 

proximal 
phalanx,  85 


Anatomy,    cross-section,    two    centi- 
meters above  joint,  89 
of  forearm,  150 

five     centimeters     above 

radial  styloid,  151 
nine     centimeters     above 

radial  styloid,  153 
in    relation   to   infections, 

149 
seven    centimeters    above 

radial  styloid,  153 
three    centimeters    above 

radial  styloid,  150 
of  hand  and  forearm,  80 
of  hypothenar  space,  95 
of  lymphatics,  310 
of  middle  palmar  space,  90 
of  thenar  space,  91 
Anesthesia  in  operations,  259 
Annular  ligament  cut  in  hand  infec- 
tions, 260,  269,  277 
extensions     of     pus     matter, 

176 

Anthrax,  390 
Arthritis,  202,  426,  432 

metacarpophalangeal,  186 
Atrophy,  426,  448 

Axillary   glands,    source   of   involve- 
ment, 328 


B 


BACILLUS  aerogenes  capsulatus  infec- 
tion, treatment  of,  389 
of  malignant  edema,  differentia- 
tion of,  386 
Bacteria    of    gas-bacillus    infections, 

differentiation  of,  386 
influence  of  types  of,  in  lymph- 
angitis, 324 

Baking  in  dry,  hot  air,  78 
Bier's  hyperemic  treatment,  71,  242, 

259.  285,  363 

treatment  of  adhesions,  288 
Bloodless  field  in  operations,  259 
Bone  involvement,  430 
Bones  of  finger,  treatment  of,  when 

involved,  436 

of  wrist-joint,  necrosis  of,  422 
Bursitis,  radial,  diagnosis  of,  222 


456 


INDEX 


CARBOLIC  acid  gangrene,  257 
Carbuncles,  38 

anatomical  considerations  of,  38 

pathogenesis  of,  38 

pathology  of,  38 

site  of,  38 

treatment  of,  42 
Carpals,  involvement  and  treatment 

of,  436 

Cautery  to  open  abscesses,  76 
Claw-hand,  211 
Collar-button  abscess,  treatment  of, 

55 

Contractures,  426,  448 
Cross-sections  of  hand  and  forearm. 

See  Anatomy. 


DISTAL  palmar  abscess,  52 
Diverticula  of  each  of  definite  spaces, 

116 
Dorsal  abscess,  diagnosis  of,  231 

as  extension  from  thenar 

space  infection,  181 
from      middle     palmar 

abscess,  180 
subaponeurotic  space,  100 

experimental  study  of 
boundaries  and  posi- 
tion of  secondary 
abscesses  in  case  of 
rupture  from,  143 
subcutaneous  spaces,  100 

boundaries,  diverticula, 
and  position  of  sec- 
ondary abscess  in  case 
of  rupture  from,  148 
experimental  study  of 
boundaries  and  posi- 
tion of  secondary 
abscess  in  case  of 
rupture  from,  141 

Dorsum  of  hand  and  forearm,  lymph- 
angitis and,  329 
infections  beginning  in,  200 
tendon  sheaths  of,  1 14 

infection   of,    treatment 

of,  283 

Drainage  in  incisions  in  forearm,  270 
in  infections,  75 
in  palmar  abscess,  291 
in  tenosynovitis,  259,  284 
at  wrist,  270 
Dressing,  alcohol,  257 

dry,  in  tenosynovitis,  285 
hot,  moist,  in  lymphangitis,  361 
in    tenosynovitis,     256, 
285 


Drugs,  antagonistic,  in  lymphangitis, 

366 
Durillon  force",  322 


E 


EDEMA  of  dorsum,  differentiated  from 

erysipelas,  328, 
mistaken  for  pus,  180 
malignant,  388 
in  tenosynovitis,  211 
Embryology  of    hand,    comparative, 

1.43 
Epitrochlear  glands,  source  of  involve- 

ment, 328 
Erysipelas,  383 

differentiated     from     edema     of 

dorsum,  328 
from  lymphangitis,  362 
gangrenous,  383 
treatment  of,  383 
Erysipeloid,  384 
Esmarch  bandage,  329 
Excretion,    stimulation    of,  in    infec- 

tions, 77 

Extensor    carpi    radials    longior    and 
brevior,  tendon  sheath  of, 

113 

ulnaris,   tendon    sheath    of, 

113 

communis     digitorum,      tendon 

sheath  of,  1  13 

indicis,  tendon  sheath  of,  113 
longus  pollicis,  tendon  sheath  of, 


minimi  digiti,  tendon  sheath  of, 

H3 

ossis   metacarpi   pollicis,   tendon 
sheath  of,  1  13 


F 


FACTORY  prophylaxis,  70 

Fascia  palmaris,  isolated  necrosis  of, 

243 

abscess  of,  acute,  prognosis 

and  resume  of,  305 
after-treatment  in,  304 
diagnosis  of,  223 
pathogenesis  of,  163 
pathology  of,  204,  206 
surgical     considerations 

of,  163 

symptoms,     signs,    and 
diagnosis  of,  209,  223 
treatment  of,  289 

immobilization    in, 

304 

experiments  as  to  boundaries, 
diverticula,  and  extensions 
from,  143 


INDEX 


457 


Fascial  spaces,  extension  of,  from  one 

to  another,  175 
of  forearm,  experimental  in- 
jection of,  154 
infection  of,  63 

direct  implantation  of 
infection  in  spaces, 
169 

etiology  of,  163 
relation  to  lymphangitis, 

173.  309 

involvement  of,  168 

recapitulation      as      to 

source  of,  183 
normal  boundaries  of,  128 
position  of  secondary  abscess 

in,  128 
relation     of,      to     synovial 

sheaths,  115 
to  tendon  sheaths,  127 
study    of,    by    serial    cross- 
sections,  83 
Felons,  25 

after-treatment  of,  31 
etiology  of,  25 
pathogenesis  of,  26 
pathology  of,  26 
treatment  of,  29 
Filleaux,  245,  246 
Fillmans,  249 

Finger,  index,  diagnosis  of  extension 
from  infections  beginning 
in,  217 

experimental  study  of  exten- 
sion   after    rupture  from 
tendon  sheath  of,  125 
infection  involving,  185 
tendon  sheath  of,  103 

extensions  from  in- 
fections in,  189 
relation  of,  to  the- 

nar  space,  104 
tenosynovitis   of,    treatment 

of,  261 
infectious  processes  of,  427 

course      of      lymphatic 

from  each,  328 
extensions  from  primary 

foci  on,  185 
involving  sides  of,  175 
involvement  of,  433 
little,     diagnosis     of     extensions 
from  infections  beginning 
in,  198,  212 

experimental  study  of  exten- 
sion   after    rupture    from 
tendon  sheath  of,  120 
infection     of,    incision      in, 

264 
tendon  sheath  of,  106 

relation  of,  to  mid- 
dle palmar  space, 
104, 


Finger,  little,  tenosynovitis  of,  treat- 
ment of,  263 
and  ulnar  bursa,  extensions 

from,  treatment  of,  270 
middle,    diagnosis    of    extension 
from  infections  beginning 
in,  195,  217 

experimental  study  of  exten- 
sion   after    rupture    from 
tendon  sheath  of,  118 
extensions    from    tenosyno- 
vitis of,  treatment  of,  263 
tendon  sheath  of,  105 

relation  of,  to  mid- 
dle palmar  space, 
1 06 

ring,  diagnosis  of  extensions  from 
infections  beginning  in, 
197,  217 

experimental  study  of  exten- 
sion   after    rupture    from 
tendon  sheath  of,  119 
extensions    from    tenosyno- 
vitis of,  treatment  of,  263 
tendon  sheath  of,  105 

extensions  of,  199 
relation       of,       to 
middle       palmar 
space,  1 06 
Flexor  longus  pollicis,  tendon  sheath 

of,  107 

tenosynovitis  of,  221 
Forearm,  abscess  of,  deep,  396 
diagnosis  of,  232 
subcutaneous,  395 
treatment  of,  416 
anatomy  of,  79 

in  relation  to  infections,  149 
dissection  and  experimental  in- 
jections of,  159 
incisions  in,  -drainage  in,  270 
infections  of,  treatment  of,  271 
injections    of   fascial    spaces   of, 

154 

involvement     of,  abscess  forma- 
tion    without     complica- 
tions, 397 
associated    with    wrist-joint 

invasion,  403 

following    tenosynovitis    of 
thumb,      treatment      of, 

273 

incision  in,  268 
from     infections     of    hand, 

pathology    and    diagnosis 

of,  395 
from  middle  palmar  space, 

175 
secondary  hemorrhage  and, 

411 

treatment  of,  416 
to  little  finger  infection, 
212,  215 


458 


INDEX 


Forearm,  involvement  of,   from  ulnar 

bursitis,  treatment  of,  266 
lymphatics  of,  318 
serial  cross-sections  of,  150 

Forssell,  234,  238 

Friedrich,  249 

Frog-felon,  52 


GANGRENE,  carbolic  acid,  257 
Gangrenous  erysipelas,  383 
Gas-bacillus  infection,  385 
Gauze  in  treatment  of  infections,  76 
Gonorrheal  tenosynovitis,  234 
Gutta-percha  in  treatment  of  infec- 
tions, 76 


HAND,  anatomy  of,  79 

chronic    processes    in    palm    of, 

treatment  of,  437 
and  forearm,   lymphatic  vessels 

of,  312 

infections,    diagnosis    of    differ- 
ential, 233 
Heineke,  244 
Helferich,  250 
Hemolysis  in  streptococcus  infections, 

325 
Hemorrhage  in  forearm  involvement, 

412 

secondary,  treatment  of,  272,  414 
Hot  air,  baking  in  dry,  78 
Hyperemic  treatment,  Bier's,  71,  242, 

259.  285,  363 
Hypothenar  space,  96,  100,  242 

abscess  of,  treatment  of,  289 
anatomy  of,  96 
boundaries,  diverticula,  and 
position  of  secondary  ab- 
scess  in   case   of   rupture 
from,  147 

experimental  study  of  bound- 
aries, diverticula,  and  posi- 
tion of  secondary  abscesses 
in  cases  of  rupture  from, 
144 

infection  of,  diagnosis  of,  241 
relation  of,  to  infection 
in      middle      palmar 
space,  1 80 

involvement  of,  source  of, 
183 


ICE-BAG  in  axilla  in  treatment  of  in- 
fections, 257 


Immobilization    in    fascial-space  ab- 
scesses, 304 
in  tenosynovitis,  285 
Incision  in  forearm  involvement,  268 

errors  in  making,  269 
in  infections,  prophylactic,  74 
in  little  finger  infections,  264 
in  lymphangitis,  364 
in  tenosynovitis,  259 
in  ulnar  bursal  infections,  264 
Index  finger.     See  Finger,  index. 
Infections.     See  also   Tenosynovitis, 
Lymphangitis,       Fascial-space 
infection, 
carbuncular,  38 
chronic,  repeated,  374 
staphylococcus,  49 
classification  of,  17 
diagnosis  of,  general,  57 
drainage  "in,  76 
grave,  57 

passive  hyperemia  in,  71 
simple  localized,  25 
spread  of,  from  any  given  pri- 
mary focus,  185 
from    one    fascia!    space    to 

another,  176 
from  sides  of  fingers,  175 
subepithelial,  37 
treatment  of,  Bier's,  71 

boric  acid  solution  in,  72 
cautery  to  open  abscesses  in, 

A    7'5 

drainage  in,  75 
drugs  in,  70 
gauze  in,  75 

general  principles  of,  70 
gutta-percha  in,  75, 
hot,  moist  dressings  in,  72 
Klapp  suction  cup  in,  77 
massage  in,  78 
passive  hyperemia  in,  71 
prophylactic  incision  in,  74 
rest  in,  170 
rubber  tubes  in,  76 
types  of,  17 
Intermediary  palmar  sheath,  anterior, 

in 

posterior,  no 

Interosseous  artery,  anterior,  lymph- 
atic abscesses  and,  175 
Interphalangeal  joint,  proximal,  rela- 
tion of,  to  tendon  sheath,  103 
Iodine  in  prophylaxis,  70 


JOINTS,  interphalangeal,  218 

proximal,  treatment  of,  when 

involved,  435 

involved     secondary     to     little 
finger  infection,  212 


INDEX 


459 


Joints,  metacarpophalangeal,  involve- 
ment and  treatment  of,  437 
preserving  function  of,  in  teno- 
synovitis,  286 


KARENSKI,  238 
Kausch,  237 
Klapp,  72,  236,  237,  447 
Konig,  247 


LACUNAE  of  lymphatics,  relation  of,  to 

subcutaneous  abscess,  328,  365 
Lejars,  250 

Leukocytosis,  increase  of,  in  lymph- 
angitis, 368 
Lexer,  248 

Little  finger.    See  Finger,  little. 
Lumbrical  muscles,  extension  to  thenar 
space  from  middle  palmar 
space,  181 

involved   from    infection   of 
middle    finger, 

195,  218 
of    tendon    sheath, 

169,  190,  218 
in  web,  197 
from      middle      palmar 

space,  176 
from  ring  finger  tendon 

sheath,  197,  218 
secondary  to  index  teno- 
synovitis,     treat- 
ment of,  261,  262 
to  little  finger  infec- 
tion, 216 
involvement    of,    source    of, 

176 

relations  of,  to  infections  of 
middle  palmar  space,  103, 
172,  262 

tenpsynovitis  and,  260 
Lymphangitis,  58 

acute,  simple,  338 

with  minor  local  complica- 
tions, 338 

with  serious  local  complica- 
tions, 339 
with  systemic  involvement, 

.342 

bacteria  and,  324 
in  central  part  of  palm,  200 
complications   of,   treatment   of, 

370 

deep,  343 

differentiated  from  erysipelas,  362 
dressing  in,  361 
drugs  in,  antagonistic,  366 


Lymphangitis,  etiology  of,  322,  333 
extension  of,  in  infection  of  middle 

finger,  195 
of  thumb,  194 

frequency  of  localization  in,  342 
hot,  moist  dressings  in,  372 
incisions  in,  364 

leukocytosis  in,  increases  of,  368 
pathogenesis  of,  322,  333 
pathology  of,  322,  333 
phlegmpnous,  341 
prognosis  of,  357 
relation  of,  to  fascial-space  infec- 
tion, 309 
to  other  types  of  infection, 

309 

to  tenosynovitis,  309 
septicemia  and,  310 
symptoms  and  signs  of,  337 
systemic  involvement  from,  346 
treatment  of,  361 

normal  salt  solution  in,  366 

peptonized  food  in,  366 
types  of,  309,  338 
Lymphatic  abscess  along  arteries,  175 

experimental  injections  and, 

331 

dilatations,  sacciform,  312 
infections,  treatment  of,  361 

rest  in,  363 
Lymphatics,  anatomy  of,  310,  312 

influence    of,    on    course    of 

infection,  326 
course  of,  174 

deep,  320,  330 

fascial-space  infection  and,  173 
history  of,  18 

relation  of,  tendon  sheaths,  329 
superficial,  312 
termination  of,  319 


M 


MALIGNANT  edema,  388 

Mascagni,  310 

Massage  in  treatment  of  infections, 

77 

Mauclaire,  249 
Median  nerve,  relation  of,  to  bursae, 

108 

Metacarpal  bones,  extension  of  infec- 
tion of,  to  dorsum,  180 
fifth,  relation  of,  to  infection 
of  hypothenar  space,   172 
involvement  and  treatment 

of,  437 

of  middle  finger,  195 
osteomyelitis   of,    198,    199, 

200 
relation  of,  to  infections  of 

middle  palmar  space,  172 
Metacarpophalangeal  arthritis,  187 


460 


INDEX 


Metacarpophalangeal    joint   and   the 

tendon  sheath,  103 
Middle  finger.    See  Finger,  middle, 
palmar  space.    See  Palmar  space, 
middle. 


N 


NECROSIS  of  bones  of  wrist,  422 

of  tendons,  205,  274 
Nerves  to  thenar  muscles,  relation  of, 

to  tendon  sheath,  273 
Nicaise,  241,  255 
Normal  salt  solution  in  lymphangitis, 

366 


OIDIOMYCOSIS,  45 

diagnosis  of,  47 
Osteomyelitis,  426 

metacarpal  bones,  198,  199,  200 


PALM,  infections  beginning  in,  200 
lymphatics  of,  317 

relation  of,  to  infections,  326 
wound  of,  punctured,  135 
Palmar  abscess,  drainage  in,  291 

fascia,  relation  of,  to  abscesses, 

200 
sheath,     intermediary,    anterior, 

in 

posterior,  no 
space,  middle,  90,  100 

abscess  of,  treatment  of, 

290 

anatomy  of,  90,  97 
boundaries,   diverticula, 
and  position  of  second- 
ary abscesses  in  case 
of  rupture  from,  145 
experimental    study    of 
boundaries 
and  position 
of  secondary 
abscess       in 
case    of    ex- 
tension from 
128 

of  site   of   rup- 
ture and  ex- 
tensions into 
forearm,  157 
infections       of,       after 

results   of,    206 
diagnosis  of,  224 
by    direct    implanta- 
tion, 169 


Palmar  space,    middle,    infections   of, 
extension  from, 
176 
to  thenar  space, 

179 
to    ulnar    bursae, 

181 

relation  of,  to  hypo- 

thenar  space,  180 

involved  from  infection 

spreading      from 

sides    of    fingers, 

175 

secondary  to  fascial 
space  infec- 
tion, 181 
to  little  finger 
infect  i  on, 
216 

to  middle  and 
ring  finger 
tenosyno- 
vitis,  168, 
198,  219 
to  ring  finger 
inf  e  ct  i  on, 
197 

to      tenosyno- 
vitis,     treat- 
ment of,  262, 
271 
involvement   of,    source 

of,  183 

and          subaponeurotic 
spaces,   combined   in- 
volvement   of,    treat- 
ment of,  297 
and  thenar  space,  com- 
bined        in- 
volv  e  m  e  n  t 
of,         treat- 
ment of,  293 
interrelation  of, 

97 

Parona,  250 
Paronychia,  31 

pathology  of,  32 

treatment  of,  33 

types  of,  32 

Peptonized  food  in  lymphangitis,  366 
Periglandular  abscess,   treatment  of, 

373 
Phalanges,  distal,  25 

infection  of,  25 
involvement    of    joints    of, 

treatment  of,  261 
Phalanx,  436 

involved  secondary  to  little  finger 

infection,  212 
middle,  218 
Phlegmon  of  dorsum,  treatment  of, 

372 
Phlegmonous  lymphangitis,  341 


INDEX 


461 


Poirier,  310 

Poulsen,  253 

Punctured  wound  of  palm,  200 


RADIAL  artery,  abscesses  along,   175 
bursa,  105 

anatomy  peculiar  to   infec- 
tions, 403 
communication       of,       with 

ulnar  bursa,  no 
diagnosis  of  extensions  from 
infections     beginning     in, 

221 

experimental    study   of   site 
of  rupture  and  extension 
into  forearm  from,  155 
infections  of,  extension  of,  to 

ulnar  bursa,  166 
treatment  of,  273 
involved  secondary  to  little 
finger     infection, 

212,  215 

to  tenosynovitis  of 

throat,  222 

bursitis,  diagnosis  of,  222 
lymphatics,  abscesses  of,  175 
•Rheumatism  of  wrist,  233 
Ring  finger.    See  Finger,  ring. 
Rubber  tubes  in  treatment  of  infec- 
tions, 76 
"Run-around"  paronychia,  31 


S 


SACCIFORM  lymphatic  dilatations,  312 

Sappey,  310 

Scneide,  244 

Schleich,  252 

Schuller,  245,  255 

Septicemia,  346 

Serum    and    vaccine    treatment    in 

lymphangitis,  367 
Shirt-stud  abscess,  52 
Sinuses  in  chronic  processes,  438 

treatment  of,  446 
Sporotrichosis,  330 
Staphylococcic  tenosynovitis,  211 
Strep tococcic  tenosynovitis,  211 
Streptococcus  infections,  hemolysis  in, 

325 
Subaponeurotic    space,     abscess    of, 

treatment  of,  303 

Subaponeurotic  space,  boundaries, 
diverticula,  and  position  of 
secondary  abscesses  in  case 
of  rupture  from,  146 
infection  from,  extension  of, 
181 


Subaponeurotic  space,  infection  from, 
secondary    changes   fol- 
lowing, 208 
source  of,  173,  181 
treatment  of,  297,  303 
Subcutaneous  abscess  following  radial 
bursal        inflammation, 
treatment  of,  274 
tenosynovitis,      treatment 

of,  272 

tissue,  source  of  infection,  173 
Subepithelial  abscess,  37 
Symbiosis,  effect  of,  on  course  of  infec- 
tion, 325 
Synovial  sacs,  accessory,  no 

sheaths  of  dorsum,  infections  of, 

treatment  of,  283 
fascial  spaces  and,   relation 

between,  115 
of  wrist-joint,  422 


TENDONS,  necrosis  of,  205,  274 

treatment  of,  447 
prevention    of    adhesions    of,    in 

tenosynovitis,  286 
prolapse  at  wrist  prevented  after 

incision,  285 
sheaths,  anatomical  distribution 

and  relations  of,  102 
upon  dorsum,  113 
extension   to   fascial   spaces 

from,  1  68 

from  little  finger,  198 
extensor    carpi    radialis 
longior          and 
brevior,  113 
ulnaris,  113 
communis       digitorum, 

113         * 
indicis,  113 
longus  pollicis,  113 
minimi  digiti,  113 
ossis  metacarpi  pollicis, 


of 


to   fascial    spaces,    relations 

of,  127 

of  flexor  longus  pollicis,  105 
e  x  p  e  r  imental 
study  of  ex- 
tension after 
rupture 
from,  126 
surface,  102 
tendon  of  little  finger, 

1  06 

of  index  finger,  experimental 
study    of  extension   after 
rupture  from,  125 
intercommunication  of,  no 


462 


INDEX 


Tendon  sheaths  of  little  finger,  106 

experimental  study 
of  extension  after 
rupture  from,  120 
of  middle  finger,  experimen- 
tal study  of  ex- 
tension         after 
rupture  from,  118 
infection        involv- 

*     •       «    ing>  I95     '        t  i 
of  ring  nnger,  experimental 

study   of   extension    after 

rupture  from,  119 

rupture   of,    relation   of,    to 

fascial  spaces,  118 
of  thumb,  anatomical  study 
of,     relation     of,     to 
motor  nerves  of  the- 
nar  muscles,  273 
spread   of  infection   in- 
volving, 194 

of  thumb,  removal  of,  275 
Tenosynovitis,  59 

acute  suppurative,  treatment  of, 

256 
adhesions  in,  211 

prevention  of,  286 
after-treatment  of,  284 

position  of  hand  in,  286 
by  aspiration,  diagnosis  of,  261 
diagnosis  of,  209 
drainage  in,  259,  284 
dressing  in,  dry,  285 

hot,  moist,  256,  285 
edema  in,  211 
etiology  of,  163 
extension  of,  from  one  sheath  to 

another,  165 
of  flexor  longus  pollicis,  221 

extension  from,  221 
following    lymphangitis,       treat- 
ment of,  370 
gonorrhe.al,  234 
incision  in,  259 
of  index  finger,  treatment  of,  259 

261 
involvement  of  various  sheaths 

in,  164 
of    little    finger,    treatment    of, 

263 

lumbrical  space  and,  260 
of    middle    finger,    treatment  of, 

259 

pathogenesis  of,  163 
pathology  of,  204 
preserving  function  of  joints  in, 

286 

prognosis  of,  305 
relation  of,  to  lymphangitis,  309 
of    ring     finger,     treatment    of, 

259 

staphylococcic,  211 
streptococcic,  211 


Tenosynovitis,   subcutaneous  abscess 

following,  treatment  of,  272 
surgical  considerations  of,  163 
symptoms  and  signs  of,  209 
tenderness  in,  210 
of  thumb,  treatment  of,  256 
treatment  of,  235,  256 

elevation  of  part  in,  257 
immobilization  in,  285 
passive    and    active    move- 
ments in,  286 
rest  in,  257 

Thenar  area,  involved  secondary  to 
index  tenosynovitis,  treatment 
of,  261,  262 
space,  91 

abscess  of  treatment  of,  301 
anatomy  of,  91,  96 
boundaries,  diverticula,  and 
position  of  secondary  ab- 
scesses in  case  of  rupture 
from,  146 

experimental        study        of 

boundaries    and    position 

of    secondary    abscess    in 

case  of  rupture  from,  134 

infection  of,  diagnosis  of,  224 

extension  of,  to  middle 

palmar  space,  1 80 

to  other  spaces,  180 

from  tendon  sheath,  190 

involved  from  infection  from 

sides  of  fingers,  175 
from   metacarpophalan- 

geal  arthritis,  187 
from      middle      palmar 

space,  179 

secondary       to      index 
finger    tenosyno- 
vitis, 219 
to  tendon-sheath  in 

fection,  169 

involvement  of,  source  of,  1 83 
middle  palmar  abscess  and, 

treatment  of,  297 
space       and,       inter- 
relation of,  97 

Thiersch   graft   after   carbuncles,    45 
Thrombophlebitis,  353 
Thumb,  infection  involving,  194 
tendon  sheath  of,  105 

extension     of     rupture 

from,  126 
tenosynovitis    of,    treatment    of, 

273 

Toxins,   virulent,   prevention   of   ab- 
sorption of,  259 


U 


ULNAR  artery,  abscesses  along,  175 
hemorrhage  and,  415 


INDEX 


463 


Ulnar  bursa,  106 

communication      of,       with 

radial  bursa,  1 1 1 
with   tendon   sheath   of 
ring,      middle,      and 
index  finger,  1 1 1 
experimental    study   of    site 
of  rupture  and  extension 
into  forearm,  156 
extensions    from,    treatment 

of,  270 
infection  of,  extension  of,  to 

radial  bursa,  166 
incision  in,  265 
involved  from  middle  palmar 

space  infection,  181 
secondary  to  little  finger 

infection,  212 
to  radial  bursal  in- 
fection, diagnosis 
of,  222 

tenosynovitis   of,   treatment 
of,  263 


Ulnar  sheath  infection,  secondary  to 
radial  bursal  inflammation,  treat- 
ment of,  275 


VON  VOLKMANN  treatment  of  teno- 
synovitis, 285 

W 

WEB  of  finger,  infection  from,  199 
involved,  secondary  to  tenosyno- 
vitis, treatment  of,  262 
space,  101 

Wound  of  palm,  punctured,  200 
Wrist  rheumatism  of,  263 
Wrist-joint,  bones  of,  necrosis  of,  422 
infection  of,  preservation  of  func- 
tion in,  423 
secondary    to    little    finger 

involvement,  212 
involvement  of,  403 

treatment  of,  421 
resection  of,  436 


Date  Due 


CAT.    NO     ?3   233 


PRINTED    IN    U.S.A. 


WE832 
Kl6i 


Kanavel  . 

Infections  of  the  hand 


WE832 
KL6i 


Kanavel . 

Infections  of  the  hand 


PRINTED   IH   U   •  A 


